Question: The mechanism of action of the medication given blocks cell wall synthesis, which of the following was given?

Context: A 21-year-old sexually active male complains of fever, pain during urination, and inflammation and pain in the right knee.

Context: A culture of the joint fluid shows a bacteria that does not ferment maltose and has no polysaccharide capsule.

Choices:
A. Gentamicin
B. Ciprofloxacin
C. Ceftriaxone
D. Trimethoprim

Answer: Ceftriaxone

4. Patient complains of pain during urination.

5. Patient complains of inflammation and pain in the right knee.

6. Culture of joint fluid shows a bacteria.

8. Bacteria has no polysaccharide capsule.

9. Physician orders antibiotic therapy for the patient.

1. A culture of the joint fluid shows a bacteria.

2. The bacteria does not ferment maltose.

3. The bacteria has no polysaccharide capsule.

4. The physician orders antibiotic therapy for the patient.


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

Context: A 5-year-old girl is brought to the emergency department by her mother because of multiple episodes of nausea and vomiting that last about 2 hours.

Context: The vomiting was preceded by fatigue.

Context: Her immunizations are up-to-date.

Context: She appears emaciated.

Context: Examination shows dry mucous membranes.

Context: The lungs are clear to auscultation.

Choices:
A. Cyclic vomiting syndrome
B. Gastroenteritis
C. Hypertrophic pyloric stenosis
D. Gastroesophageal reflux disease

Answer: Cyclic vomiting syndrome

1. A 5-year-old girl is brought to the emergency department by her mother.

2. She has had multiple episodes of nausea and vomiting that last about 2 hours.

3. During this period, she has had 6–8 episodes of bilious vomiting and abdominal pain.

4. The vomiting was preceded by fatigue.

5. She feels well between these episodes.

6. She has missed several days of school and has been hospitalized 2 times during the past 6 months for dehydration due to similar episodes of vomiting and nausea.

7. The patient has lived with her mother since her parents divorced 8 months ago.

9. She is at the 60th percentile for height and 30th percentile for weight.

11. Her temperature is 36.8°C (98.8°F), pulse is 99/min, and blood pressure is 82/52 mm Hg.

12. Examination shows dry mucous membranes.

13. The lungs are clear to auscultation.

14. Abdominal examination shows a soft abdomen with mild diffuse tenderness with no guarding or rebound.

15. The remainder of the physical examination shows no abnormalities.

1. The patient has had 6–8 episodes of bilious vomiting and abdominal pain.

2. The vomiting was preceded by fatigue.

3. The girl feels well between these episodes.

4. She has missed several days of school.

5. She has been hospitalized 2 times during the past 6 months for dehydration due to similar episodes of vomiting and nausea.

6. The patient has lived with her mother since her parents divorced 8 months ago.

8. She is at the 60th percentile for height and 30th percentile for weight.

10. Her temperature is 36.8°C (98.8°F), pulse is 99/min, and blood pressure is 82/52 mm Hg.

11. Examination shows dry mucous membranes.

12. The lungs are clear to auscultation.

13. Abdominal examination shows a soft abdomen with mild diffuse tenderness with no guarding or rebound.

14. The remainder of the physical examination shows no abnormalities.


Question: Which of the following is the best course of treatment in this patient?

Context: A 40-year-old woman presents with difficulty falling asleep, diminished appetite, and tiredness for the past 6 weeks.

Context: She says that, despite going to bed early at night, she is unable to fall asleep.

Context: She says she has grown increasingly irritable and feels increasingly hopeless, and her concentration and interest at work have diminished.

Context: Because of her diminished appetite, she has lost 4 kg (8.8 lb) in the last few weeks and has started drinking a glass of wine every night instead of eating dinner.

Context: She has no significant past medical history and is not on any medications.

Choices:
A. Diazepam
B. Paroxetine
C. Zolpidem
D. Trazodone

Answer: Trazodone

2. Patient has difficulty falling asleep for the past 6 weeks.

3. Patient goes to bed early at night but is unable to fall asleep.

4. Patient denies feeling anxious or having disturbing thoughts while in bed.

5. Patient wakes up early in the morning and is unable to fall back asleep.

6. Patient has grown increasingly irritable and feels increasingly hopeless.

7. Patient's concentration and interest at work have diminished.

8. Patient denies thoughts of suicide or death.

9. Patient has lost 4 kg (8.8 lb) in the last few weeks.

10. Patient has started drinking a glass of wine every night instead of eating dinner.

11. Patient has no significant past medical history.

1. The patient has trouble falling asleep despite going to bed early at night.

2. She denies feeling anxious or having disturbing thoughts while in bed.

3. Even when she manages to fall asleep, she wakes up early in the morning and is unable to fall back asleep.

4. The patient has grown increasingly irritable and feels increasingly hopeless.

5. Her concentration and interest at work have diminished.

6. The patient denies thoughts of suicide or death.

7. She has lost 4 kg (8.8 lb) in the last few weeks due to diminished appetite.

8. She has started drinking a glass of wine every night instead of eating dinner.

9. The patient has no significant past medical history and is not on any medications.


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

Context: A 37-year-old female with a history of type II diabetes mellitus presents to the emergency department complaining of blood in her urine, left-sided flank pain, nausea, and fever.

Context: Vital signs include: temperature is 102 deg F (39.4 deg C), blood pressure is 114/82 mmHg, pulse is 96/min, respirations are 18, and oxygen saturation of 97% on room air.

Context: On physical examination, the patient appears uncomfortable and has tenderness on the left flank and left costovertebral angle.

Choices:
A. Obtain an abdominal CT scan
B. Obtain a urine analysis and urine culture
C. Begin intravenous treatment with ceftazidime
D. No treatment is necessary

Answer: Obtain a urine analysis and urine culture

1. A 37-year-old female presents to the emergency department.

2. She has a history of type II diabetes mellitus.

3. She is complaining of blood in her urine, left-sided flank pain, nausea, and fever.

4. She also states that she has pain with urination.

5. Her temperature is 102 deg F (39.4 deg C).

9. Her oxygen saturation is 97% on room air.

10. On physical examination, she appears uncomfortable.

11. She has tenderness on the left flank.

12. She has tenderness on the left costovertebral angle.

1. The patient reports pain with urination.

2. Vital signs: temperature is 102 deg F (39.4 deg C), blood pressure is 114/82 mmHg, pulse is 96/min, respirations are 18, and oxygen saturation of 97% on room air.

3. On physical examination, the patient appears uncomfortable.

4. The patient has tenderness on the left flank.

5. The patient has tenderness on the left costovertebral angle.


Question: Which of the following should be treated first in this patient?

Context: A 19-year-old boy presents with confusion and the inability to speak properly.

Context: The patient's mother says that, a few hours ago, she noticed a change in the way he talked and that he appeared to be in a daze.

Context: He then lost consciousness, and she managed to get him to the hospital.

Context: She is also concerned about the weight he has lost over the past few months.

Context: His blood pressure is 80/55 mm Hg, pulse is 115/min, temperature is 37.2°C (98.9°F), and respiratory rate is 18/min.

Context: He is unable to cooperate for a mental status examination.

Context: Results of his arterial blood gas analysis are shown. | Pco2 16 mm Hg | HCO3–  10 mEq/L | Po2 91 mm Hg | pH 7.1 | His glucose level is 450 mg/dL, and his potassium level is 4.1 mEq/L.

Choices:
A. Hypoperfusion
B. Hyperglycemia
C. Metabolic acidosis
D. Hypokalemia

Answer: Hypoperfusion

2. Patient presents with confusion and inability to speak properly.

3. Patient's mother noticed a change in the way he talked and he appeared to be in a daze a few hours ago.

4. Patient lost consciousness and mother managed to get him to the hospital.

5. Mother is concerned about weight loss over past few months.

6. Patient's blood pressure is 80/55 mm Hg.

8. Patient's temperature is 37.2°C (98.9°F).

9. Patient's respiratory rate is 18/min.

10. Patient is taking rapid, deep breaths.

12. Patient has dry mucous membranes and dry skin.

13. Patient is unable to cooperate for mental status examination.

18. Patient's glucose level is 450 mg/dL.

19. Patient's potassium level is 4.1 mEq/L.

1. The patient's mother noticed a change in the way he talked and that he appeared to be in a daze.

3. The patient's blood pressure is 80/55 mm Hg.

5. The patient's temperature is 37.2°C (98.9°F).

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

7. On physical examination, the patient is taking rapid, deep breaths, and his breath has a fruity odor.

8. Dry mucous membranes and dry skin are noticeable.

9. The patient is unable to cooperate for a mental status examination.

10. Results of his arterial blood gas analysis: Pco2 16 mm Hg, HCO3– 10 mEq/L, Po2 91 mm Hg, pH 7.1.

11. The patient's glucose level is 450 mg/dL.

12. The patient's potassium level is 4.1 mEq/L.


Question: Which of the following represents the most likely etiology of her anemia.

Context: A 41-year-old woman presents to her primary care physician with complaints of fatigue and weakness.

Context: She denies any personal history of blood clots or bleeding problems in her past, but she says that her mother has had to be treated for breast cancer recently and is starting to wear her down.

Context: Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

Context: She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and currently denies any illicit drug use.

Context: Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 111/min; and respiratory, rate 23/min.

Context: On physical examination, her pulses are bounding and irregular, complexion is pale, but breath sounds remain clear.

Context: On examination, the physician finds diffuse skin pallor and orders a complete blood count.

Context: Her laboratory data demonstrate a hematocrit of 27.1%, MCV of 79 fL, and a reticulocyte count of 2.0%.

Context: The patient is diagnosed with anemia.

Choices:
A. Vitamin B12 deficiency
B. Folate deficiency
C. Iron deficiency
D. Intravascular hemolysis

Answer: Iron deficiency

2. Patient complains of fatigue and weakness.

3. Patient denies personal history of blood clots or bleeding problems.

4. Patient's mother has been treated for breast cancer recently.

5. Patient's past medical history includes preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

6. Patient smokes 1 pack of cigarettes per day.

7. Patient drinks 1 glass of wine per day.

9. Patient's temperature is 36.7°C (98.0°F).

10. Patient's blood pressure is 126/74 mm Hg.

12. Patient's respiratory rate is 23/min.

13. Patient's pulses are bounding and irregular.

16. Physician finds diffuse skin pallor.

17. Physician orders complete blood count.

20. Patient's reticulocyte count is 2.0%.

1. Patient denies personal history of blood clots or bleeding problems.

2. Patient's mother has been treated for breast cancer recently.

3. Patient's past medical history includes preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia.

4. Patient currently smokes 1 pack of cigarettes per day.

5. Patient drinks a glass of wine per day.

7. Vital signs: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 111/min, respiratory rate 23/min.

8. Patient's pulses are bounding and irregular.

11. Physician finds diffuse skin pallor and orders a complete blood count.

12. Laboratory data: hematocrit 27.1%, MCV 79 fL, reticulocyte count 2.0%.


Question: Which of the following is the most likely primary mechanism underlying this woman's temporal muscle atrophy?

Context: A 59-year-old woman with stage IV lung cancer comes to the physician because of progressively worsening weakness in the past 3 months.

Context: She has had a 10.5-kg (23-lb) weight loss during this period.

Context: Her BMI is 16 kg/m2.

Context: She appears thin and has bilateral temporal wasting.

Choices:
A. Cytochrome c-mediated activation of proteases
B. Lipase-mediated degradation of triglycerides
C. TNF-α-mediated activation of caspases
D. Proteasomal degradation of ubiquitinated proteins

Answer: Proteasomal degradation of ubiquitinated proteins

1. A 59-year-old woman has stage IV lung cancer.

2. She has experienced progressively worsening weakness in the past 3 months.

3. She has lost 10.5 kg (23 lbs) in the past 3 months.

1. She has had a 10.5-kg weight loss during this period.

2. The weight loss is equivalent to 23 lbs.


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

Context: The patient has a past medical history of dementia, diabetes, and hypertension and typically has a visiting home nurse come to administer medications.

Context: Laboratory studies are drawn as seen below. |  | Hemoglobin: 15 g/dL | Hematocrit: 45% | Leukocyte count: 4,500/mm^3 with normal differential | Platelet count: 227,000/mm^3 |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 24 mEq/L | BUN: 30 mg/dL | Glucose: 97 mg/dL | Creatinine: 1.5 mg/dL | Ca2+: 10.2 mg/dL | AST: 12 U/L | ALT: 10 U/L |  | Urine: | Color: Yellow | Bacteria: Absent | Nitrites: Negative | Red blood cells: Negative |  | An initial chest radiograph is unremarkable.

Choices:
A. Exertional heat stroke
B. Neuroleptic malignant syndrome
C. Non-exertional heat stroke
D. Septic shock

Answer: Non-exertional heat stroke

1. A 67-year-old man presents to the emergency department with a fever and altered mental status.

2. The patient has a history of Alzheimer dementia and is typically bed bound.

3. His son found him confused with a warm and flushed complexion thus prompting his presentation.

4. The patient has a past medical history of dementia, diabetes, and hypertension.

5. The patient typically has a visiting home nurse come to administer medications.

6. Prior to examination, he is given haloperidol and diphenhydramine as he is combative and will not allow the nurses near him.

7. His temperature is 102.9°F (39.4°C), blood pressure is 104/64 mmHg, pulse is 170/min, respirations are 22/min, and oxygen saturation is 100% on room air.

8. Physical exam is notable for dry and flushed skin and a confused man.

9. There is no skin breakdown, and flexion of the patient’s neck elicits no discomfort.

10. Laboratory studies show a hemoglobin of 15 g/dL, hematocrit of 45%, leukocyte count of 4,500/mm^3 with normal differential, and platelet count of 227,000/mm^3.

11. Serum Na+ is 139 mEq/L, Cl- is 100 mEq/L, K+ is 4.3 mEq/L, HCO3- is 24 mEq/L, BUN is 30 mg/dL, glucose is 97 mg/dL, creatinine is 1.5 mg/dL, Ca2+ is 10.2 mg/dL, AST is 12 U/L, and ALT is 10 U/L.

12. Urine color is yellow, bacteria are absent, nitrites are negative, and red blood cells are negative.

13. An initial chest radiograph is unremarkable.

14. The patient is given 3 liters of Ringer's lactate and an electric fan to cool off.

15. Two hours later, his temperature is 99°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 100% on room air.

16. The patient’s mental status is at the

1. The patient has a history of Alzheimer dementia.

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

4. The patient typically has a visiting home nurse come to administer medications.

5. Prior to examination, the patient is given haloperidol and diphenhydramine.

6. The patient's temperature is 102.9°F (39.4°C).

7. The patient's blood pressure is 104/64 mmHg.

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

10. The patient's oxygen saturation is 100% on room air.

11. Physical exam is notable for dry and flushed skin and a confused man.

13. Flexion of the patient’s neck elicits no discomfort.

14. Laboratory studies show: Hemoglobin: 15 g/dL, Hematocrit: 45%, Leukocyte count: 4,500/mm^3 with normal differential, Platelet count: 227,000/mm^3, Serum: Na+: 139 mEq/L, Cl-: 100 mEq/L, K+: 4.3 mEq/L, HCO3-: 24 mEq/L, BUN: 30 mg/dL, Glucose: 97 mg/dL, Creatinine: 1.5 mg/dL, Ca2+: 10.2 mg/dL, AST: 12 U/L, ALT: 10 U/L, Urine: Color: Yellow, Bacteria: Absent, Nitrites: Negative, Red blood cells: Negative.

15. An initial chest radiograph is unremarkable.

16. The patient is given 3 liters of Ringer's lactate and an electric fan to cool off.

17. Two hours later, the patient’s temperature is 99°F (37.2°C).

18. The patient’s blood pressure is 154/94 mmHg.

20. The patient’s respirations are 17/min.

21. The patient’s oxygen saturation is 100% on room air.

22. The patient’s mental status is at the patient’s baseline according to the son.


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

Context: A 32-year-old man presents to a mission hospital in Cambodia because he has had difficulty walking from his village to the market.

Context: He says that he has always been healthy other than occasional infections; however, over the last year he has been having numbness in his hands and feet.

Context: Furthermore, he has noticed weakness, muscle wasting, and pain in his lower extremities.

Context: Physical exam reveals normal skin color and decreased deep tendon reflexes.

Choices:
A. Alpha-ketoglutarate dehydrogenase
B. Acyl transferases
C. Glycogen phosphorylase
D. Homocysteine methyltransferase

Answer: Alpha-ketoglutarate dehydrogenase

1. A 32-year-old man presents to a mission hospital in Cambodia.

2. He has had difficulty walking from his village to the market.

3. He has always been healthy other than occasional infections.

4. Over the last year he has been having numbness in his hands and feet.

5. He has noticed weakness, muscle wasting, and pain in his lower extremities.

6. The only change he can remember is that after having a poor harvest last year, he and his family have been subsisting on white rice.

7. Physical exam reveals normal skin color.

8. Physical exam reveals decreased deep tendon reflexes.

1. He has always been healthy other than occasional infections.

2. Over the last year, he has been having numbness in his hands and feet.

3. He has noticed weakness, muscle wasting, and pain in his lower extremities.

4. After having a poor harvest last year, he and his family have been subsisting on white rice.

5. Physical exam reveals normal skin color.

6. Physical exam reveals decreased deep tendon reflexes.


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

Context: She has a past medical history of hypertension and was discharged from the hospital yesterday after management of a myocardial infarction.

Context: Her temperature is 99.5°F (37.5°C), blood pressure is 147/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air.

Context: Physical exam is within normal limits.

Choices:
A. Atenolol
B. Furosemide
C. Hydrochlorothiazide
D. Nitroglycerin

Answer: Atenolol

1. A 60-year-old woman presents to her primary care physician for a wellness checkup.

2. She has a past medical history of hypertension.

3. She was discharged from the hospital yesterday after management of a myocardial infarction.

4. She states that sometimes she experiences exertional angina.

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

10. Physical exam is within normal limits.

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

2. The patient was discharged from the hospital yesterday after management of a myocardial infarction.

3. The patient sometimes experiences exertional angina.

4. The patient's temperature is 99.5°F (37.5°C).

5. The patient's blood pressure is 147/98 mmHg.

7. The patient's respirations are 17/min.

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

9. The physical exam is within normal limits.


Question: When this hormone is produced by the hypothalamus, it has which of the following effects?

Context: A 42-year-old male presents to his primary care physician complaining of abdominal pain.

Context: He reports a 5-month history of epigastric pain that improves with meals.

Choices:
A. Decrease production of growth hormone
B. Decrease production of prolactin
C. Decrease production of gastrin
D. Decrease production of thyrotropin-releasing hormone

Answer: Decrease production of growth hormone

1. A 42-year-old male presents to his primary care physician.

3. He has a 5-month history of epigastric pain that improves with meals.

4. He has lost 15 pounds since the pain started.

5. His past medical history is significant for a prolactinoma for which he underwent transphenoidal resection.

7. He has a 10 pack-year smoking history.

8. His family history is notable for a maternal uncle with a parathyroid adenoma.

13. He is started on octreotide, an analogue of an endogenously produced hormone.

1. The patient reports a 5-month history of epigastric pain that improves with meals.

2. He has lost 15 pounds since the pain started.

3. His past medical history includes a prolactinoma for which he underwent transphenoidal resection.

4. He drinks alcohol socially and has a 10 pack-year smoking history.

5. His family history includes a maternal uncle with a parathyroid adenoma.

6. His temperature is 98.8°F (37.1°C), blood pressure is 125/80 mmHg, pulse is 85/min, and respirations are 18/min.

7. After further workup, the patient is started on octreotide, an analogue of an endogenously produced hormone.


Question: What is the minimum amount of time this patient must exhibit these symptoms in order to meet the diagnostic criteria for dysthymia?

Context: A 28-year-old female reports that, for more days than not over the past 3 years, she has felt "down" and, at times, "mildly depressed." Over this period, she also endorses feeling fatigued, difficulty concentrating, and often sleeping more than in the past.

Context: The patient denies any manic or hypomanic periods and also reports that she did not have any periods of extreme worsening of her depressed mood beyond that described above.

Context: She also denies any suicidal ideation.

Choices:
A. 2 months
B. 6 months
C. 2 years
D. 5 years

Answer: 2 years

2. Patient has felt "down" and "mildly depressed" for more days than not over the past 3 years.

4. Patient endorses difficulty concentrating.

5. Patient has been sleeping more than in the past.

6. Patient denies any manic or hypomanic periods.

7. Patient denies any periods of extreme worsening of her depressed mood beyond that described above.

8. Patient denies any suicidal ideation.

1. The patient denies any manic periods.

2. The patient denies any hypomanic periods.

3. The patient reports not having any periods of extreme worsening of her depressed mood beyond that described above.

4. The patient denies any suicidal ideation.


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

Context: A 42-year-old man is being treated by his female family medicine physician for chronic depression.

Context: Recently, he has been scheduling more frequent office visits.

Context: Upon further questioning, the patient confesses that he is attracted to her and says "You are the only one in the world who understands me".

Context: The physician also manages his hypertension.

Choices:
A. Re-evaluate this patient for borderline personality disorder
B. Ask closed-ended questions and use a chaperone for future visits
C. Immediately tell this patient that you can not continue to treat him and avoid any further communication
D. Increase the dosage of this patient’s SSRI

Answer: Ask closed-ended questions and use a chaperone for future visits

1. A 42-year-old man is being treated by his female family medicine physician.

3. The patient has been scheduling more frequent office visits.

4. The patient does not report any symptoms or problems with his SSRI medication during these visits.

5. Upon further questioning, the patient confesses that he is attracted to his physician.

6. The patient says "You are the only one in the world who understands me".

7. The physician also manages the patient's hypertension.

1. He has been scheduling more frequent office visits.

2. He does not report any symptoms or problems with his SSRI medication during these visits.

3. The patient confesses that he is attracted to her.

4. The patient says "You are the only one in the world who understands me."

5. The physician manages his hypertension.


Question: What is the most likely cause of the gallstone coloring?

Context: The physician suspects she is suffering from biliary colic and recommends surgery.

Choices:
A. E. coli infection; beta-glucoronidase release
B. Shigella infection; HMG-CoA reductase release
C. Shigella infection; beta-glucoronidase release
D. Bile supersaturated with cholesterol; beta-glucoronidase release

Answer: E. coli infection; beta-glucoronidase release

1. A 51-year-old female presents with intermittent right upper quadrant discomfort.

2. The physician suspects she is suffering from biliary colic.

4. Following surgery, brown stones are removed from the gallbladder specimen.

1. The physician suspects the patient is suffering from biliary colic.

2. The physician recommends surgery for the patient.

3. Brown stones are removed from the gallbladder specimen following surgery.


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

Context: A 56-year-old man with known coronary artery disease presents to the emergency department complaining of chest discomfort and palpitations for 2 hours.

Context: Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2 shown below.

Choices:
A. Monomorphic ventricular tachycardia
B. Mitral regurgitation
C. Third-degree heart block
D. Acute pericarditis

Answer: Monomorphic ventricular tachycardia

Cardiovascular Disease
Clinical Cardiac Electrophysiology

1. A 56-year-old man with known coronary artery disease presents to the emergency department.

2. The patient is complaining of chest discomfort and palpitations for 2 hours.

3. On arrival, the vital signs include blood pressure 122/76 mm Hg, heart rate 180/min, respiratory rate 22/min, temperature 37.0℃ (98.6℉), and blood oxygen saturation (SpO2) 98% on room air.

4. A 12-lead electrocardiogram demonstrated ST-segment elevation in the anterolateral leads.

5. The troponin level was 0.8 ng/mL (normal 0–0.4 ng/mL).

6. The patient declined primary percutaneous intervention and was treated with antifibrinolytics in the coronary care unit.

7. After 1 hour of treatment, the patient loses consciousness and the blood pressure falls to 60/40 mm Hg.

8. Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2.

1. Vital signs on arrival: blood pressure 122/76 mm Hg, heart rate 180/min, respiratory rate 22/min, temperature 37.0℃ (98.6℉), and blood oxygen saturation (SpO2) 98% on room air.

2. 12-lead electrocardiogram demonstrated ST-segment elevation in the anterolateral leads.

3. Troponin level was 0.8 ng/mL (normal 0–0.4 ng/mL).

4. Patient declined primary percutaneous intervention and was treated with antifibrinolytics in the coronary care unit.

5. After 1 hour of treatment, the patient loses consciousness.

7. Cardiac monitoring shows the electrocardiogram (ECG) pattern in lead 2.


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

Context: A 16-year-old female high school student is brought to the physician by her parents for her repeated behavioral problems at home and school during the past 10 months.

Context: Her teachers describe her behavior as uncooperative and disruptive as she persistently refuses to answer questions, insults her teachers, and annoys her classmates on a daily basis.

Context: At home, her parents try to address her frequent violations of curfew, but attempts at discussing the issue often result in their daughter losing her temper and screaming at her parents.

Context: On questioning, the patient refuses to answer and frequently disrupts the physician’s conversation with the parents.

Choices:
A. Reactive attachment disorder
B. Conduct disorder
C. Antisocial personality disorder
D. Oppositional defiant disorder

Answer: Oppositional defiant disorder

1. Patient is a 16-year-old female high school student.

2. Patient was brought to the physician by her parents.

3. Patient has had repeated behavioral problems for 10 months.

4. Patient's teachers describe her behavior as uncooperative and disruptive.

5. Patient refuses to answer questions, insults teachers, and annoys classmates on a daily basis.

6. Patient's parents have tried to address her frequent violations of curfew.

7. Attempts at discussing the issue often result in the patient losing her temper and screaming at her parents.

8. Patient's grades have deteriorated over the past year.

9. Patient has no history of psychiatric illness.

10. Patient refuses to answer and frequently disrupts the physician's conversation with the parents.

1. Her teachers describe her behavior as uncooperative and disruptive.

2. She persistently refuses to answer questions.

4. She annoys her classmates on a daily basis.

5. Her parents try to address her frequent violations of curfew.

6. Attempts at discussing the issue often result in their daughter losing her temper and screaming at her parents.

7. Her grades have deteriorated over the past year.

8. She has no history of psychiatric illness.

9. On questioning, the patient refuses to answer.

10. She frequently disrupts the physician’s conversation with the parents.


Question: Which of the following findings indicates that the cause of shock is cardiogenic?

Context: A 22-year-old man is brought to the emergency room with a penetrating stab injury to his left chest.

Context: His pulse is feeble, systolic blood pressure is 86 mm Hg, the respirations are 22/min with an oxygen saturation of 88% at room air, and the temperature is 36.6°C (98.0°F).

Context: His jugular vein is distended.

Context: Chest auscultation reveals equal breath sounds bilaterally, with muffled heart sounds.

Choices:
A. Elevated serum creatinine
B. High central venous pressure (CPV)
C. Arterial blood gas (ABG) showing base deficit and metabolic acidosis
D. White blood cell (WBC) count < 4000/mm3

Answer: High central venous pressure (CPV)

General Emergency Medicine
Cardiovascular Disease

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

2. He has a penetrating stab injury to his left chest.

3. He appears pale, drowsy, and diaphoretic.

5. His systolic blood pressure is 86 mm Hg.

7. His oxygen saturation is 88% at room air.

10. Chest auscultation reveals equal breath sounds bilaterally.

11. Chest auscultation reveals muffled heart sounds.

12. Immediate IV fluid resuscitation is initiated.

1. The patient appears pale, drowsy, and diaphoretic.

5. Oxygen saturation is 88% at room air.

8. Chest auscultation reveals equal breath sounds bilaterally.

10. Immediate IV fluid resuscitation is initiated.


Question: Which of the following characteristics best describes the most likely causal pathogen?

Context: A 56-year-old woman is brought to the physician by her husband because of a two-day history of fever, malaise, headaches, and confusion.

Context: She recently immigrated from rural China and her immunization status is unknown.

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

Context: However, when the sheep blood agar sample is heated, numerous non-hemolytic, opaque, cream-colored colonies grow.

Choices:
A. Gram-negative coccobacillus
B. Gram-positive, lancet-shaped diplococcus
C. Gram-negative diplococcus
D. Gram-positive, facultative intracellular bacillus

Answer: Gram-negative coccobacillus

Infectious Disease
General Infectious Disease

1. A 56-year-old woman is brought to the physician by her husband.

2. She has a two-day history of fever, malaise, headaches, and confusion.

3. She recently immigrated from rural China.

6. Physical examination shows nuchal rigidity and photophobia.

7. Cerebrospinal fluid analysis shows a neutrophil count of 1,500/mm3.

8. Cerebrospinal fluid cultured on Thayer-Martin agar and normal sheep blood agar shows no growth.

9. When the sheep blood agar sample is heated, numerous non-hemolytic, opaque, cream-colored colonies grow.

1. She recently immigrated from rural China.

4. Physical examination shows nuchal rigidity and photophobia.

5. Cerebrospinal fluid analysis shows a neutrophil count of 1,500/mm3.

6. Cerebrospinal fluid cultured on Thayer-Martin agar and normal sheep blood agar shows no growth.

7. When the sheep blood agar sample is heated, numerous non-hemolytic, opaque, cream-colored colonies grow.


Question: The pathogen associated with this patient’s condition is also known to cause which of the following?

Context: A 35-year-old male presents to his primary care physician complaining of a one-month history of progressively worsening fatigue.

Context: He sought medical attention because this has affected his ability to complete his work as a graduate student.

Context: As a child, he was hospitalized for hemolytic uremic syndrome.

Context: His past medical history is also notable for diabetes mellitus and obesity.

Context: He takes metformin and glyburide.

Context: He does not smoke and drinks alcohol occasionally.

Context: His family history is notable for chronic lymphocytic leukemia in his paternal uncle and stroke in his father.

Context: His temperature is 99.9°F (37.7°C), blood pressure is 100/70 mmHg, pulse is 110/min, and respirations are 18/min.

Context: Hematologic labs are shown below: |  | Hemoglobin: 8.9 g/dL | Hematocrit: 24% | Leukocyte count: 7,500 cells/mm^3 with normal differential | Platelet count: 180,000/mm^3 | Mean corpuscular volume: 85 µm^3 | Reticulocyte count: 0.4% |  | Head and neck imaging is negative for neck masses.

Choices:
A. Kaposi’s sarcoma
B. Erythema infectiosum
C. Mononucleosis
D. Croup

Answer: Erythema infectiosum

2. Patient has a one-month history of progressively worsening fatigue.

3. Patient sought medical attention because fatigue has affected his ability to complete his work as a graduate student.

4. Patient was hospitalized for hemolytic uremic syndrome as a child.

5. Patient has past medical history of diabetes mellitus and obesity.

6. Patient takes metformin and glyburide.

7. Patient does not smoke and drinks alcohol occasionally.

8. Patient's family history is notable for chronic lymphocytic leukemia in his paternal uncle and stroke in his father.

9. Patient's temperature is 99.9°F (37.7°C).

10. Patient's blood pressure is 100/70 mmHg.

13. Physical examination reveals diffuse pallor.

16. Leukocyte count is 7,500 cells/mm^3 with normal differential.

20. Head and neck imaging is negative for neck masses.

1. The patient sought medical attention due to an impact on his ability to complete his work as a graduate student.

2. As a child, the patient was hospitalized for hemolytic uremic syndrome.

3. The patient's past medical history includes diabetes mellitus and obesity.

4. The patient takes metformin and glyburide.

5. The patient does not smoke and drinks alcohol occasionally.

6. The patient's family history includes chronic lymphocytic leukemia in his paternal uncle and stroke in his father.

7. The patient's temperature is 99.9°F (37.7°C).

8. The patient's blood pressure is 100/70 mmHg.

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

11. Physical examination reveals diffuse pallor.

14. Leukocyte count: 7,500 cells/mm^3 with normal differential

18. Head and neck imaging is negative for neck masses.


Question: Which of the following is the best treatment for the most likely cause for this patient’s illness?

Context: She complains that over the past week there have been 3 episodes where he has fallen asleep while speaking with her.

Context: She mentioned that these events began a few months ago and have been increasing in frequency.

Context: She also says that his snoring has gotten to the point where she has a hard time sleeping next to him.

Context: He is worried he might be “going crazy.” He has noticed that when his friends tell him a joke or he laughs at something on the TV, he drops whatever he’s holding and feels like his legs become weak.

Choices:
A. Modafinil
B. Taking longer naps
C. Continuous positive airway pressure
D. Changing bedtime to earlier in the evening

Answer: Modafinil

Sleep Medicine
Pulmonary Disease
General Sleep Medicine

1. A 30-year-old man is brought to the doctor's office by his wife.

2. The wife complains that over the past week there have been 3 episodes where he has fallen asleep while speaking with her.

3. The wife mentions that these events began a few months ago and have been increasing in frequency.

4. The wife also says that his snoring has gotten to the point where she has a hard time sleeping next to him.

5. When asked, the patient says that he frequently falls asleep while reading or watching television in the afternoons and feels refreshed after a short nap.

6. The patient is worried because he sometimes hears people who aren’t in the room as he falls asleep.

7. He is worried he might be “going crazy.”

8. He has noticed that when his friends tell him a joke or he laughs at something on the TV, he drops whatever he’s holding and feels like his legs become weak.

9. These episodes self-resolve in a few seconds.

10. Examination shows a morbidly obese man in no acute distress.

1. The patient has experienced 3 episodes of falling asleep while speaking over the past week.

2. The events of falling asleep began a few months ago and have been increasing in frequency.

3. The patient's snoring has reached a point where it affects her ability to sleep next to him.

4. The patient frequently falls asleep while reading or watching television in the afternoons and feels refreshed after a short nap.

5. The patient hears people who aren't in the room as he falls asleep, causing worry about his mental health.

6. The patient experiences weakness in his legs and drops objects when laughing, but the episodes self-resolve in a few seconds.

7. The examination shows a morbidly obese man in no acute distress.


Question: Which of the following is the best next treatment for this patient?

Context: Laboratory values are ordered as seen below. |  | Hemoglobin: 8.0 g/dL | Hematocrit: 30% | Leukocyte count: 3,500/mm^3 with normal differential | Platelet count: 192,000/mm^3 | MCV: 119 fL |  | Serum: | Na+: 139 mEq/L | Cl-: 100 mEq/L | K+: 4.3 mEq/L | HCO3-: 25 mEq/L | BUN: 20 mg/dL | Glucose: 47 mg/dL | Creatinine: 1 mg/dL | Ca2+: 9.2 mg/dL | Mg2+: 1.2 mEq/L | AST: 82 U/L | ALT: 70 U/L |  | .

Choices:
A. Folate
B. Magnesium
C. Thiamine
D. Vitamin C

Answer: Thiamine

General Emergency Medicine
Neurocritical Care

1. A 55-year-old homeless man presents to the emergency department acutely confused.

2. The patient was found wandering the streets with an abnormal gait.

3. The patient has a past medical history of alcohol and IV drug abuse.

8. Oxygen saturation is 97% on room air.

9. Physical exam is notable for a poorly kempt man with ataxic gait.

10. Ophthalmoplegia is noted on cranial nerve testing.

11. He has decreased vibration sensation in the bilateral lower extremity.

12. Dermatologic exam reveals perifollicular hemorrhages, bleeding gums, and many bruises along the patient’s upper and lower extremities.

13. An initial ECG is notable for sinus tachycardia.

14. The patient is given 2L of Ringer lactate.

17. Leukocyte count: 3,500/mm^3 with normal differential.

1. The patient was found wandering the streets with an abnormal gait.

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

3. His temperature is 98.5°F (36.9°C), blood pressure is 103/61 mmHg, pulse is 120/min, respirations are 16/min, and oxygen saturation is 97% on room air.

4. Physical exam is notable for a poorly kempt man with ataxic gait.

5. Ophthalmoplegia is noted on cranial nerve testing, and he has decreased vibration sensation in the bilateral lower extremity.

6. Dermatologic exam reveals perifollicular hemorrhages, bleeding gums, and many bruises along the patient’s upper and lower extremities.

7. An initial ECG is notable for sinus tachycardia and the patient is given 2L of Ringer lactate.

8. Laboratory values: Hemoglobin: 8.0 g/dL, Hematocrit: 30%, Leukocyte count: 3,500/mm^3 with normal differential, Platelet count: 192,000/mm^3, MCV: 119 fL, Serum: Na+: 139 mEq/L, Cl-: 100 mEq/L, K+: 4.3 mEq/L, HCO3-: 25 mEq/L, BUN: 20 mg/dL, Glucose: 47 mg/dL, Creatinine: 1 mg/dL, Ca2+: 9.2 mg/dL, Mg2+: 1.2 mEq/L, AST: 82 U/L, ALT: 70 U/L.


Question: Which of the following is the most likely initial step in the pathogenesis of this patient's coronary condition?

Context: A 61-year-old woman is brought to the emergency department because of crushing substernal chest pain at rest for the past 2 hours.

Context: She is diaphoretic.

Context: Her temperature is 37.5°C (99.5°F), pulse is 110/min, respirations are 21/min, and blood pressure is 115/65 mm Hg.

Choices:
A. Intimal monocyte infiltration
B. Platelet activation
C. Endothelial cell dysfunction
D. Fibrous plaque formation

Answer: Endothelial cell dysfunction

Cardiovascular Disease
General Cardiology

1. A 61-year-old woman is brought to the emergency department.

2. She has crushing substernal chest pain at rest for the past 2 hours.

8. An ECG shows ST elevation in I, aVL, and V2–V4.

9. Coronary angiography shows an 80% stenosis in the left anterior descending artery.

6. An ECG shows ST elevation in I, aVL, and V2–V4.

7. Coronary angiography shows an 80% stenosis in the left anterior descending artery.


Question: What is the most likely etiology of this patient’s presentation?

Context: She states that the patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

Context: The patient is afebrile and all vital signs are stable.

Choices:
A. Patent processus vaginalis
B. Collection of fluid in the tunica vaginalis
C. Infection of the epididymis
D. Neoplasm of the testicle

Answer: Patent processus vaginalis

1. A 4-year-old boy presents to the office with his mother.

2. The patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

3. On exam, the abdomen is soft and nontender to palpation.

4. The right scrotal sac is mildly enlarged without erythema.

5. A tender mass is palpated in the right scrotal area.

6. The mass does not transilluminate when a penlight is applied.

1. The patient has been complaining of pain in his scrotum with swelling, abdominal pain, and nausea for the last 2 or 3 days.

2. On exam, the abdomen is soft and nontender to palpation.

3. The right scrotal sac is mildly enlarged without erythema.

4. A tender mass is palpated in the right scrotal area.

5. The mass does not transilluminate when a penlight is applied.


Question: What is the most likely diagnosis?

Context: A 59-year-old man presents to his primary care physician, accompanied by his wife, who requests treatment for his “chronic pessimism.” The patient admits to feeling tired and “down” most of the time for the past several years but insists that it is “just part of getting old.” His wife believes that he has become more self-critical and less confident than he used to be.

Context: He has continued to work as a librarian at a nearby college during this time and spends time with friends on the weekends.

Context: He sleeps 7 hours per night and eats 3 meals per day.

Choices:
A. Adjustment disorder with depressive features
B. Bipolar disorder
C. Cyclothymia
D. Dysthymia

Answer: Dysthymia

1. A 59-year-old man presents to his primary care physician.

3. His wife requests treatment for his “chronic pessimism.”

4. The patient admits to feeling tired and “down” most of the time for the past several years.

5. He insists that it is “just part of getting old.”

6. His wife believes that he has become more self-critical and less confident than he used to be.

7. Neither the patient nor his wife can identify any stressors or triggering events.

8. He has continued to work as a librarian at a nearby college during this time.

9. He spends time with friends on the weekends.

12. He denies suicidal ideation or periods of elevated mood, excessive irritability, or increased energy.

13. Physical exam reveals a well-dressed, well-groomed man without apparent abnormality.

14. Basic neurocognitive testing and labs (CBC, BMP, TSH, cortisol, testosterone, and urine toxicology) are within normal limits.

1. The patient and his wife cannot identify any stressors or triggering events.

2. He has continued to work as a librarian at a nearby college.

3. He spends time with friends on the weekends.

10. Physical exam reveals a well-dressed, well-groomed man without apparent abnormality.

11. Basic neurocognitive testing and labs (CBC, BMP, TSH, cortisol, testosterone, and urine toxicology) are within normal limits.


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

Context: A 17-month-old girl was brought to the emergency department by her mom following a fall.

Context: She had an uncomplicated birth history and has been meeting developmental goals except for language delay, for which she is to receive a hearing test for further evaluation next week.

Context: Physical exam reveals bruising along the left lateral thigh, knee, and elbow; all lab tests are within normal limits.

Choices:
A. Child abuse
B. Defective type 1 collagen gene
C. Low levels of phosphate
D. Low levels of vitamin D

Answer: Defective type 1 collagen gene

Child Abuse Pediatrics
Pediatric Emergency Medicine

1. A 17-month-old girl was brought to the emergency department by her mom.

2. The mom reports that the patient was playing in the playground when she tripped and fell onto the mulch.

3. She had an uncomplicated birth history.

4. She has been meeting developmental goals except for language delay.

5. She is to receive a hearing test for further evaluation next week.

6. Physical exam reveals bruising along the left lateral thigh, knee, and elbow.

7. All lab tests are within normal limits.

8. Radiograph shows a fracture of the olecranon.

9. Serum chemistry and liver panels were within normal limits.

1. The patient was playing in the playground when she tripped and fell onto the mulch.

2. The patient had an uncomplicated birth history.

3. The patient has been meeting developmental goals except for language delay.

4. The patient is to receive a hearing test for further evaluation next week.

5. Physical exam reveals bruising along the left lateral thigh, knee, and elbow.

6. All lab tests are within normal limits.

7. Radiograph shows a fracture of the olecranon.

8. Serum chemistry was within normal limits.

9. Liver panels were within normal limits.


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

Context: ِA 62-year-old man comes to the emergency department because of colicky pain in the lower abdomen and abdominal distension for the past 12 hours.

Context: His temperature is 37.1°C (98.7°F), blood pressure is 110/60 mm Hg and pulse is 85/min.

Context: On physical examination, there is diffuse abdominal distension and tenderness, and bowel sounds are faint.

Choices:
A. Infectious colitis
B. Bowel adhesions
C. Volvulus
D. Acute diverticulitis

Answer: Volvulus

1. A 62-year-old man comes to the emergency department.

2. He has colicky pain in the lower abdomen and abdominal distension for the past 12 hours.

3. He has chronic constipation for which he takes lactulose and senna laxatives.

7. On physical examination, there is diffuse abdominal distension and tenderness.

9. His plain abdominal radiograph is shown.

2. He takes lactulose and senna laxatives.

6. On physical examination, there is diffuse abdominal distension.

7. On physical examination, there is tenderness.


Question: The addition of this drug is most likely to increase the risk of which of the following adverse effects?"

Context: He is 180 cm (5 ft 11 in) tall and weighs 110 kg (242 lb); BMI is 34 kg/m2.

Context: Serum lipid studies show: | Cholesterol, total 302 mg/L | HDL-cholesterol 39 mg/dL | LDL-cholesterol 197 mg/dL | Triglycerides 292 mg/dL | The physician prescribes a drug that inhibits intestinal cholesterol absorption.

Choices:
A. Hepatotoxicity
B. Hyperkalemia
C. Cutaneous flushing
D. Hyperuricemia

Answer: Hepatotoxicity

Geriatric Medicine
General Internal Medicine

1. A 73-year-old African American man comes to the physician for a routine health maintenance examination.

2. He has type 2 diabetes mellitus, hypertension, hypercholesterolemia, and coronary artery disease.

3. His current medications include metformin, hydrochlorothiazide, amlodipine, rosuvastatin, isosorbide mononitrate, aspirin, and dipyridamole.

7. His vital signs are within normal limits.

8. His hemoglobin A1c concentration is 6.7%.

13. The physician prescribes a drug that inhibits intestinal cholesterol absorption.

5. His current medications include metformin.

6. His current medications include hydrochlorothiazide.

7. His current medications include amlodipine.

8. His current medications include rosuvastatin.

9. His current medications include isosorbide mononitrate.

10. His current medications include aspirin.

11. His current medications include dipyridamole.

15. His vital signs are within normal limits.

16. His hemoglobin A1c concentration is 6.7%.

17. Serum lipid studies show: Cholesterol, total 302 mg/L.

18. Serum lipid studies show: HDL-cholesterol 39 mg/dL.

19. Serum lipid studies show: LDL-cholesterol 197 mg/dL.

20. Serum lipid studies show: Triglycerides 292 mg/dL.

21. The physician prescribes a drug that inhibits intestinal cholesterol absorption.


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

Context: A 15-year-old girl is brought to the clinic by her mother because she is worried the patient has not yet had her period.

Context: Her body mass index (BMI) is 19 kg/m^2.

Choices:
A. CYP17 gene work-up
B. Estrogen levels
C. Gonadotrophin-releasing hormone stimulation test
D. Karotype

Answer: Karotype

Pediatric Endocrinology
Pediatric Gynecology

2. Patient's mother brought her to the clinic.

3. Patient's mother is worried because patient has not had her period.

4. Patient's older sister had her first period at age 14.

5. Patient's mother had her first period at age 13.

6. Patient reports she is doing well in school.

7. Patient is on the varsity basketball team.

8. Patient has a medical history of asthma and atopic dermatitis.

9. Patient's medications include albuterol and topical triamcinolone.

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

11. Patient's blood pressure is 111/72 mmHg.

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

16. Physical exam shows absent breast development and external genitalia at Tanner stage 1.

17. Serum follicle stimulating hormone (FSH) level is measured to be 38 mIU/mL.

1. The patient’s older sister had her first period at age 14.

2. The mother had her first period at age 13.

3. The patient reports she is doing well in school and is on the varsity basketball team.

4. Her medical history is significant for asthma and atopic dermatitis.

5. Her medications include albuterol and topical triamcinolone.

6. The patient’s temperature is 98°F (36.7°C), blood pressure is 111/72 mmHg, pulse is 65/min, and respirations are 14/min with an oxygen saturation of 99% on room air.

7. Her body mass index (BMI) is 19 kg/m^2.

8. Physical exam shows absent breast development and external genitalia at Tanner stage 1.

9. Serum follicle stimulating hormone (FSH) level is measured to be 38 mIU/mL.


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

Context: A 15-month-old girl is brought to the physician by her mother for grossly bloody diarrhea for 2 days.

Context: Examination shows conjunctival pallor.

Context: The abdomen is soft and nontender.

Context: Her hemoglobin concentration is 9.5 g/dL, mean corpuscular volume is 68 μm3, and platelet count is 300,000/mm3.

Choices:
A. Neutrophil infiltrated crypts on colonic biopsy
B. Absent ganglionic cells on rectal suction biopsy
C. Target sign on abdominal ultrasound
D. Ectopic gastric mucosa on Technetium-99m pertechnetate scan

Answer: Ectopic gastric mucosa on Technetium-99m pertechnetate scan

1. A 15-month-old girl is brought to the physician by her mother.

2. She has had grossly bloody diarrhea for 2 days.

3. She has had a few episodes of blood-tinged stools over the past 3 weeks.

4. She has not had pain, nausea, or vomiting.

5. She is at the 55th percentile for height.

6. She is at the 55th percentile for weight.

7. Examination shows conjunctival pallor.

9. There is a small amount of dark red blood in the diaper.

10. Her hemoglobin concentration is 9.5 g/dL.

11. Her mean corpuscular volume is 68 μm3.

1. The girl has had a few episodes of blood-tinged stools over the past 3 weeks.

2. She has not had pain, nausea, or vomiting.

3. She is at the 55th percentile for height and 55th percentile for weight.

4. Examination shows conjunctival pallor.

6. There is a small amount of dark red blood in the diaper.

7. Her hemoglobin concentration is 9.5 g/dL.


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

Context: A 3855-g (8-lb 8-oz) newborn is examined shortly after birth.

Context: She was delivered at 40 weeks' gestation by cesarean delivery because of breech presentation.

Context: Pregnancy was otherwise uncomplicated.

Context: The left leg is shorter than the right leg and positioned in external rotation.

Choices:
A. Fracture of the femoral neck
B. Inflammation of the hip synovium
C. Abnormal development of the acetabulum
D. Displacement of the femoral epiphysis

Answer: Abnormal development of the acetabulum

General Orthopaedic Surgery
Pediatric Orthopaedic Surgery

1. A 3855-g newborn was examined shortly after birth.

2. The newborn was delivered at 40 weeks' gestation.

3. The newborn was delivered by cesarean delivery.

4. The cesarean delivery was due to breech presentation.

5. The pregnancy was otherwise uncomplicated.

6. Physical examination showed asymmetric thigh creases.

7. The left leg was shorter than the right leg.

8. The left leg was positioned in external rotation.

1. She was delivered at 40 weeks' gestation.

2. The delivery was by cesarean delivery.

3. The reason for the cesarean delivery was breech presentation.

4. The pregnancy was otherwise uncomplicated.

5. Physical examination shows asymmetric thigh creases.

6. The left leg is shorter than the right leg.

7. The left leg is positioned in external rotation.


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

Context: A 27-year-old G1P0 woman at 9 weeks estimated gestational age presents for a prenatal visit.

Context: She has no current complaints and takes no medications.

Context: She is vegetarian and emigrated from Nepal 7 years ago.

Context: She does not use tobacco, alcohol or recreational drugs.

Context: The patient’s vital signs include: blood pressure 111/95 mm Hg, temperature 36.7°C (98.6°F), pulse 88/min.

Context: Laboratory results are significant for the following: | Hemoglobin 10.2 g/dL | Erythrocyte count 5.5 million/mm3 | Mean corpuscular volume 65 μm3 | Mean corpuscular hemoglobin 21 pg/cell | Red cell distribution width 13.5% (ref: 11.5–14.5%) | Serum ferritin 170 ng/mL | .

Choices:
A. Vitamin B12 deficiency
B. Zinc deficiency
C. Gestational anemia
D. Thalassemia trait

Answer: Thalassemia trait

Gestational anemia
General Obstetrics and Gynecology

2. Patient is at 9 weeks estimated gestational age.

6. Patient emigrated from Nepal 7 years ago.

7. Patient does not use tobacco, alcohol or recreational drugs.

8. Patient's blood pressure is 111/95 mm Hg.

9. Patient's temperature is 36.7°C (98.6°F).

12. Patient's erythrocyte count is 5.5 million/mm3.

13. Patient's mean corpuscular volume is 65 μm3.

14. Patient's mean corpuscular hemoglobin is 21 pg/cell.

15. Patient's red cell distribution width is 13.5% (ref: 11.5–14.5%).

16. Patient's serum ferritin is 170 ng/mL.

1. The patient has no current complaints.

4. The patient emigrated from Nepal 7 years ago.

7. The patient does not use recreational drugs.

8. The patient's blood pressure is 111/95 mm Hg.

9. The patient's temperature is 36.7°C (98.6°F).

11. The patient's hemoglobin level is 10.2 g/dL.

12. The patient's erythrocyte count is 5.5 million/mm3.

13. The patient's mean corpuscular volume is 65 μm3.

14. The patient's mean corpuscular hemoglobin is 21 pg/cell.

15. The patient's red cell distribution width is 13.5% (ref: 11.5–14.5%).

16. The patient's serum ferritin level is 170 ng/mL.


Question: What will be the change in the kinetics of the reaction catalyzed by carbonic anhydrase under the influence of acetazolamide?

Context: A 31-year-old woman presents to your clinic with a persistent headache.

Context: She reports she has suffered from headaches since the age of 27 when she gained 12 kg (26.4 lb) after the birth of her second child.

Context: The patient’s blood pressure is 130/85 mm Hg, heart rate is 90/min, respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉).

Context: The patient’s weight is 101 kg (222.7 lb), height is 165 cm (5.4 ft), and BMI is 36.7 kg/m2.

Context: Examination reveals papilledema.

Choices:
A. Activation energy (Ea) will increase
B. Activation energy (Ea) will decrease
C. Free energy (G) of the reactants will increase
D. Increase reaction free energy change (∆G) by increasing free energy (G) of reactants and decreasing G of products

Answer: Activation energy (Ea) will increase

2. Patient has suffered from headaches since the age of 27.

3. Patient gained 12 kg (26.4 lb) after the birth of her second child.

4. Headache is generalized and throbbing in nature.

6. Headache is aggravated with coughing, laughing, and sneezing.

7. Patient's blood pressure is 130/85 mm Hg.

9. Patient's respiratory rate is 14/min.

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

11. Patient's weight is 101 kg (222.7 lb).

12. Patient's height is 165 cm (5.4 ft).

15. Head CT scan does not reveal any abnormalities.

16. Lumbar puncture shows an opening pressure of 32 cm H2O.

17. Patient is prescribed a carbonic anhydrase inhibitor, acetazolamide, for idiopathic intracranial hypertension.

1. The patient has suffered from headaches since the age of 27.

2. The headaches started after she gained 12 kg (26.4 lb) after the birth of her second child.

3. The headache is generalized and throbbing in nature.

4. It worsens in the morning and is aggravated with coughing, laughing, and sneezing.

5. The patient’s blood pressure is 130/85 mm Hg.

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

8. The patient’s temperature is 36.6℃ (97.9℉).

9. The patient’s weight is 101 kg (222.7 lb).

10. The patient’s height is 165 cm (5.4 ft).

13. Head CT scan does not reveal any abnormalities.

14. Lumbar puncture shows an opening pressure of 32 cm H2O.

15. The patient is prescribed a carbonic anhydrase inhibitor, acetazolamide, for idiopathic intracranial hypertension.


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

Context: A 55-year-old man comes to the emergency department because of a dry cough and severe chest pain beginning that morning.

Context: Two months ago, he was diagnosed with inferior wall myocardial infarction and was treated with stent implantation of the right coronary artery.

Context: His temperature is 38.5°C (101.3°F), pulse is 92/min, respirations are 22/min, and blood pressure is 130/80 mm Hg.

Context: An ECG shows diffuse ST elevations.

Choices:
A. Cardiac tamponade
B. Constrictive pericarditis
C. Reinfarction
D. Dressler syndrome

Answer: Dressler syndrome

Pulmonary Disease
Cardiovascular Disease

1. A 55-year-old man comes to the emergency department.

2. He has a dry cough and severe chest pain beginning that morning.

3. Two months ago, he was diagnosed with inferior wall myocardial infarction.

4. He was treated with stent implantation of the right coronary artery.

5. He has a history of hypertension and hypercholesterolemia.

6. His medications include aspirin, clopidogrel, atorvastatin, and enalapril.

11. Cardiac examination shows a high-pitched scratching sound best heard while sitting upright and during expiration.

12. The remainder of the examination shows no abnormalities.

14. Serum studies show a troponin I of 0.2 ng/mL (N < 0.01).

1. Two months ago, he was diagnosed with inferior wall myocardial infarction.

2. He was treated with stent implantation of the right coronary artery.

4. He has a history of hypercholesterolemia.

7. His medications include atorvastatin.

13. Cardiac examination shows a high-pitched scratching sound best heard while sitting upright and during expiration.

14. The remainder of the examination shows no abnormalities.

16. Serum studies show a troponin I of 0.2 ng/mL (N < 0.01).


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

Context: A 27-year-old man presents to the physician with concern for pain in both of his knees that he is unable to attribute to any activities that he has recently performed.

Context: He had an acute episode of diarrhea 2 weeks ago, prior to the onset of symptoms.

Context: He has also been experiencing a burning sensation during urination for the past week.

Context: When questioned about any other symptoms, he notes that he has also noticed that his eyes occasionally feel irritated and painful, leading to bouts of blurry vision.

Context: On physical examination, the patient is afebrile and has conjunctival injection surrounding the iris.

Context: A synovial fluid aspiration of the knee is performed and reveals a white blood cell count of 51,000/µL.

Choices:
A. Acetaminophen
B. Allopurinol
C. Indomethacin
D. Leflunomide

Answer: Indomethacin

3. Patient cannot attribute pain to any recent activities.

4. Patient had an acute episode of diarrhea 2 weeks ago.

5. Patient has burning sensation during urination for the past week.

6. Patient has noticed eyes occasionally feel irritated and painful.

8. Patient is afebrile on physical examination.

9. Patient has conjunctival injection surrounding the iris.

10. Synovial fluid aspiration of the knee reveals white blood cell count of 51,000/µL.

1. He had an acute episode of diarrhea 2 weeks ago.

2. He has been experiencing a burning sensation during urination for the past week.

3. He has noticed that his eyes occasionally feel irritated and painful, leading to bouts of blurry vision.

4. On physical examination, the patient is afebrile.

5. On physical examination, the patient has conjunctival injection surrounding the iris.

6. A synovial fluid aspiration of the knee is performed.

7. The synovial fluid aspiration of the knee reveals a white blood cell count of 51,000/µL.


Question: Of the following organisms, infection with which one is most consistent with her symptoms?

Context: A 22-year old active duty soldier presents to your clinic with complaints of intense fatigue, fevers, abdominal pain, and a nonproductive cough.

Context: Her symptoms began a few days ago, but she returned from a tour of duty in Malawi and Mozambique four weeks ago.

Context: She endorses sleeping outside, using minimal bug spray, and swimming in rivers during her tour.

Context: On physical exam, her temperature is 101.5, and she appears exhausted.

Context: She has a hive-like rash scattered over her body.

Context: Her abdominal exam is notable for hepatosplenomegaly, and her lung exam is notable for scattered crackles.

Context: Her CBC with diff is remarkable for marked eosinophilia, and she has an elevated IgE.

Choices:
A. Plasmodium falciparum
B. Schistosoma mansoni
C. Mycobacterium tuberculosis
D. Trypanosoma brucei rhodesiense

Answer: Schistosoma mansoni

1. Patient is 22-year old active duty soldier.

2. Patient presents with complaints of intense fatigue, fevers, abdominal pain, and a nonproductive cough.

4. Patient returned from a tour of duty in Malawi and Mozambique four weeks ago.

5. Patient endorses sleeping outside, using minimal bug spray, and swimming in rivers during her tour.

6. On physical exam, patient's temperature is 101.5, and she appears exhausted.

7. Patient has a hive-like rash scattered over her body.

8. Abdominal exam is notable for hepatosplenomegaly.

9. Lung exam is notable for scattered crackles.

10. CBC with diff is remarkable for marked eosinophilia.

2. She returned from a tour of duty in Malawi and Mozambique four weeks ago

5. She endorses swimming in rivers during her tour

6. On physical exam, her temperature is 101.5

8. She has a hive-like rash scattered over her body

9. Her abdominal exam is notable for hepatosplenomegaly

10. Her lung exam is notable for scattered crackles

11. Her CBC with diff is remarkable for marked eosinophilia


Question: Which of the following best describes the mechanism of action of the drug that is most likely responsible for this patient's symptoms?

Context: A 72-year-old man comes to the emergency room because of a 4-day history of progressively worsening pain and swelling on the right side of his face.

Context: The patient was diagnosed with multiple myeloma 8 months ago and is currently undergoing treatment.

Context: An orofacial fistula is present.

Choices:
A. Cross-linking DNA at guanine
B. Inhibition of proteosome activity
C. Stimulation of PTH receptor
D. Binding to hydroxyapatite

Answer: Binding to hydroxyapatite

1. A 72-year-old man comes to the emergency room.

2. He has a 4-day history of progressively worsening pain and swelling on the right side of his face.

3. He was diagnosed with multiple myeloma 8 months ago.

4. He is currently undergoing treatment.

5. His vital signs are within normal limits.

6. Physical exam shows erythema and swelling over the right cheek and mandible.

1. The patient was diagnosed with multiple myeloma 8 months ago.

2. The patient is currently undergoing treatment.

3. His vital signs are within normal limits.

4. Physical exam shows erythema and swelling over the right cheek and mandible.


Question: Which of the following is the most important risk factor for the development of this condition?

Context: A 12-month-old girl is brought to the physician because she is unable to sit and has not learned how to crawl.

Context: She babbles and does not mimic sounds.

Context: Her maternal cousin has Down syndrome.

Context: The Moro reflex is present.

Choices:
A. Premature birth
B. Congenital rubella infection
C. Congenital CMV infection
D. Advanced maternal age

Answer: Premature birth

2. Patient is unable to sit and has not learned how to crawl.

3. Patient keeps hips and elbows flexed and parents have to use considerable force to passively extend her joints.

4. Patient attained neck control at 4 months and could roll from front to back at 5 months of age.

5. Patient does not engage in play, reach for toys, or maintain eye contact.

6. Patient babbles and does not mimic sounds.

7. Patient does not follow simple instructions.

8. Patient has difficulty swallowing solid foods and often coughs at meal times.

9. Patient's maternal cousin has Down syndrome.

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

11. Patient is at the 25th percentile for length and 10th percentile for weight.

12. Neurological examination shows increased muscle tone in all extremities.

13. Ankle clonus and extensor plantar responses are present bilaterally.

15. MRI of the head shows periventricular leukomalacia.

1. She keeps her hips and elbows flexed and her parents have to use considerable force to passively extend her joints.

2. She attained neck control at 4 months and could roll from front to back at 5 months of age.

3. She does not engage in play, reach for toys, or maintain eye contact.

4. She babbles and does not mimic sounds.

5. She does not follow simple instructions.

6. She has difficulty swallowing solid foods and often coughs at meal times.

7. Her maternal cousin has Down syndrome.

8. Her vital signs are within normal limits.

9. She is at the 25th percentile for length and 10th percentile for weight.

10. Neurological examination shows increased muscle tone in all extremities.

11. The ankle clonus and extensor plantar responses are present bilaterally.

13. An MRI of the head shows periventricular leukomalacia.


Question: What is the most likely diagnosis?

Context: A 31-year-old male presents with a 2-day history of watery diarrhea that began 8 days after his arrival from Africa.

Context: His temperature is 98.6°F (37°C), respiratory rate is 15/min, pulse is 107/min, and blood pressure is 90/68 mm Hg.

Context: Intravenous fluids are started, and a stool sample is sent to the lab, which comes out to be negative for any ova/parasites, blood cells, or pus cells.

Choices:
A. Giardiasis
B. Irritable bowel syndrome (IBS)
C. Traveler’s diarrhea due to Norovirus
D. Traveler’s diarrhea due to ETEC

Answer: Traveler’s diarrhea due to ETEC

2. Patient has a 2-day history of watery diarrhea.

3. Patient's diarrhea began 8 days after his arrival from Africa.

4. None of the other members of his family became ill.

5. Patient reports symptoms of malaise, anorexia, and abdominal cramps.

6. Patient denies tenesmus, urgency, and bloody diarrhea.

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

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

10. Patient's blood pressure is 90/68 mm Hg.

11. Physical examination is within normal limits.

14. Stool sample is negative for any ova/parasites, blood cells, or pus cells.

1. None of the other members of his family became ill.

2. He reports symptoms of malaise, anorexia, and abdominal cramps followed by watery diarrhea.

3. He denies tenesmus, urgency, and bloody diarrhea.

8. A physical examination is performed and is within normal limits.

11. The stool sample comes out to be negative for any ova/parasites, blood cells, or pus cells.


Question: Which of the following is the primary cause of the patient’s lab results?

Context: A 46-year-old woman presents to the emergency department with progressive dyspnea and chest pain.

Context: She reports that her symptoms started 1 week ago and have gotten progressively worse.

Context: The chest pain is left-sided and is exacerbated by coughing or deep breaths.

Context: She also endorses a 6-month history of joint pains involving her knees, elbows, and digits.

Context: She does not have a significant medical or surgical history.

Context: She takes ibuprofen as needed.

Context: She works as a pre-school teacher.

Context: The patient’s temperature is 99°F (37.2°C), blood pressure is 120/78 mmHg, pulse is 89/min, and respirations are 17/min with an oxygen saturation of 93% on room air.

Context: On physical examination, a friction rub upon inspiration/expiration and crackles are appreciated at the base of the left lung.

Context: She has an erythematous rash that spans the bilateral cheeks and nose.

Context: There are also scattered ecchymoses on her arms and legs.

Context: A chest radiograph shows a small left-sided pleural effusion.

Context: A complete blood count is obtained, as shown below: |  | Hemoglobin: 9 g/dL | Hematocrit: 28% | Leukocyte count: 1,500/mm^3 with normal differential | Platelet count: 80,000/mm^3 |  | A urinalysis shows elevated protein levels.

Context: Serologic antibodies are pending.

Choices:
A. Hematologic malignancy
B. Immune-mediated destruction
C. Mechanical shearing
D. Viral infection

Answer: Immune-mediated destruction

Pulmonary Disease
General Pulmonary Disease

2. Patient presents to the emergency department with progressive dyspnea and chest pain.

3. Symptoms started 1 week ago and have gotten progressively worse.

4. Chest pain is left-sided and is exacerbated by coughing or deep breaths.

5. Patient has a 6-month history of joint pains involving her knees, elbows, and digits.

6. Patient does not have a significant medical or surgical history.

8. Patient works as a pre-school teacher.

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

10. Patient's blood pressure is 120/78 mmHg.

12. Patient's respirations are 17/min with an oxygen saturation of 93% on room air.

13. Physical examination reveals a friction rub upon inspiration/expiration and crackles at the base of the left lung.

14. Patient has an erythematous rash that spans the bilateral cheeks and nose.

15. Patient has scattered ecchymoses on her arms and legs.

16. Chest radiograph shows a small left-sided pleural effusion.

17. Complete blood count shows hemoglobin of 9 g/dL, hematocrit of 28%, leukocyte count of 1,500/mm^3 with normal differential, and platelet count of 80,000/mm^3.

18. Urinalysis shows elevated protein levels.

2. Symptoms have gotten progressively worse

4. Chest pain is exacerbated by coughing or deep breaths

5. 6-month history of joint pains involving knees, elbows, and digits

6. No significant medical or surgical history

13. Oxygen saturation is 93% on room air

14. Friction rub upon inspiration/expiration and crackles are appreciated at the base of the left lung

15. Erythematous rash spans the bilateral cheeks and nose

16. Scattered ecchymoses on arms and legs

17. Chest radiograph shows a small left-sided pleural effusion

20. Leukocyte count: 1,500/mm^3 with normal differential

22. Urinalysis shows elevated protein levels


Question: The cell type responsible for the regeneration of the patient's alveolar epithelium is also functions in:

Context: A 48-year-old patient is recovering from acute lung injury following a diffuse pulmonary viral infection.

Choices:
A. Protease release
B. Phagocytosis
C. Surfactant secretion
D. Recruitment of neutrophils

Answer: Surfactant secretion

2. Patient is recovering from acute lung injury.

3. Patient had a diffuse pulmonary viral infection.

2. The patient is recovering from acute lung injury.

3. The acute lung injury is following a diffuse pulmonary viral infection.


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

Context: She has generalized itching.

Context: Laboratory studies show: | Hemoglobin 13.2 g/dL | Leukocyte count 8,300/mm3 | Platelet count 280,000/mm3 | ESR 32 mm/h | Serum | Glucose 89 mg/dL | Creatinine 0.7 mg/dL | TSH 4.8 μU/ml | Bilirubin | Total 1.4 mg/dL | Direct 0.9 mg/dL | Alkaline phosphatase 480 U/L | Aspartate aminotransferase 62 U/L | Alanine aminotransferase 32 U/L | Total cholesterol 288 mg/dL | HDL-cholesterol 57 mg/dL | LDL-cholesterol 189 mg/dL | Triglycerides 212 mg/dL | γ-Glutamyl transferase 92 U/L (N = 5–50) | Antimitochondrial antibody (AMA) positive | Antinuclear antibody (ANA) positive | Urinalysis shows no abnormalities.

Choices:
A. Liver biopsy
B. Atorvastatin
C. Cholestyramine
D. Ursodeoxycholic acid

Answer: Ursodeoxycholic acid

1. A 36-year-old woman comes to the physician because of fatigue for 4 months.

2. She is unable to do her chores and complains of excessive sleepiness during the day.

4. She has not had abdominal pain, fever, or weight loss.

5. She has had chronic low back pain for 6 years.

6. Her current medications include acetaminophen and vitamin supplements.

7. Examination shows scratch marks over the trunk.

8. The remainder of the examination shows no abnormalities.

9. Laboratory studies show: Hemoglobin 13.2 g/dL.

10. Laboratory studies show: Leukocyte count 8,300/mm3.

11. Laboratory studies show: Platelet count 280,000/mm3.

12. Laboratory studies show: ESR 32 mm/h.

13. Laboratory studies show: Serum Glucose 89 mg/dL.

14. Laboratory studies show: Creatinine 0.7 mg/dL.

15. Laboratory studies show: TSH 4.8 μU/ml.

16. Laboratory studies show: Bilirubin Total 1.4 mg/dL.

17. Laboratory studies show: Direct 0.9 mg/dL.

18. Laboratory studies show: Alkaline phosphatase 480 U/L.

19. Laboratory studies show: Aspartate aminotransferase 62 U/L.

20. Laboratory studies show: Alanine aminotransferase 32 U/L.

21. Laboratory studies show: Total cholesterol 288 mg/dL.

22. Laboratory studies show: HDL-cholesterol 57 mg/dL.

23. Laboratory studies show: LDL-cholesterol 189 mg/dL.

24. Laboratory studies show: Triglycerides 212 mg/dL.

25. Laboratory studies show: γ-Glutamyl transferase 92 U/L (N = 5–50).

26. Laboratory studies show: Antimitochondrial antibody (AMA) positive.

27. Laboratory studies show: Antinuclear antibody (ANA) positive.

29. Ultrasound of the abdomen shows gallbladder sludge.

1. She is unable to do her chores and complains of excessive sleepiness during the day.

3. She has not had abdominal pain, fever, or weight loss.

4. She has had chronic low back pain for 6 years.

5. Her current medications include acetaminophen and vitamin supplements.

6. Examination shows scratch marks over the trunk.

7. The remainder of the examination shows no abnormalities.

8. Laboratory studies show: Hemoglobin 13.2 g/dL, Leukocyte count 8,300/mm3, Platelet count 280,000/mm3, ESR 32 mm/h, Serum Glucose 89 mg/dL, Creatinine 0.7 mg/dL, TSH 4.8 μU/ml, Bilirubin Total 1.4 mg/dL, Direct 0.9 mg/dL, Alkaline phosphatase 480 U/L, Aspartate aminotransferase 62 U/L, Alanine aminotransferase 32 U/L, Total cholesterol 288 mg/dL, HDL-cholesterol 57 mg/dL, LDL-cholesterol 189 mg/dL, Triglycerides 212 mg/dL, γ-Glutamyl transferase 92 U/L (N = 5–50), Antimitochondrial antibody (AMA) positive, Antinuclear antibody (ANA) positive.

10. Ultrasound of the abdomen shows gallbladder sludge.


Question: Which of the following arterial blood findings for the partial pressure of oxygen (PaO2), oxygen saturation (SaO2), and oxygen concentration (CaO2) are expected in this patient?

Context: A 40-year-old woman presents to the physician with complaints of frequent headaches and fatigue for a month.

Context: Her headaches are mild and occur at random times.

Context: They are relieved by over the counter analgesics.

Context: Furthermore, she feels tired most of the time and sometimes gets short of breath with exertion.

Context: She denies low mood, loss of interest, inability to concentrate, sleep disturbance, or suicidal ideation.

Context: She was diagnosed with Crohn’s disease 20 years ago for which she currently takes methotrexate.

Context: Additionally, she takes a folic acid-containing multivitamin daily.

Context: Her medical history is otherwise insignificant and she does not smoke, drink, or use recreational drugs.

Context: She has a pulse rate of 110/min, respiratory rate of 20/min, and temperature of 37.0°C (98.6°F).

Context: Physical examination reveals pallor in her palms and lower palpebral conjunctiva.

Choices:
A. Normal PaO2, normal SaO2, normal CaO2
B. Low PaO2, low SaO2, low CaO2
C. Low PaO2, normal SaO2, normal CaO2
D. Normal PaO2, normal SaO2, low CaO2

Answer: Normal PaO2, normal SaO2, low CaO2

2. Patient has been experiencing frequent headaches and fatigue for a month.

3. Headaches are mild and occur at random times.

4. Headaches are relieved by over the counter analgesics.

5. Patient feels tired most of the time.

6. Patient sometimes gets short of breath with exertion.

7. Patient denies low mood, loss of interest, inability to concentrate, sleep disturbance, or suicidal ideation.

8. Patient was diagnosed with Crohn’s disease 20 years ago.

9. Patient currently takes methotrexate.

10. Patient takes a folic acid-containing multivitamin daily.

11. Patient's medical history is otherwise insignificant.

12. Patient does not smoke, drink, or use recreational drugs.

13. Patient has a pulse rate of 110/min.

14. Patient has a respiratory rate of 20/min.

15. Patient has a temperature of 37.0°C (98.6°F).

16. Physical examination reveals pallor in patient's palms and lower palpebral conjunctiva.

3. Her headaches are relieved by over the counter analgesics.

5. She sometimes gets short of breath with exertion.

11. She was diagnosed with Crohn’s disease 20 years ago.

12. She currently takes methotrexate for Crohn’s disease.

13. She takes a folic acid-containing multivitamin daily.

14. Her medical history is otherwise insignificant.

17. She does not use recreational drugs.

19. She has a respiratory rate of 20/min.

20. She has a temperature of 37.0°C (98.6°F).

21. Physical examination reveals pallor in her palms.

22. Physical examination reveals pallor in her lower palpebral conjunctiva.


Question: What is the most logical diagnostic test for this patient?

Context: A 25-year-old woman complains of dyspnea and mild chest pain on exertion, which increases gradually with continued exertion.

Context: She had similar symptoms last year and her medical record included the following arterial blood gas findings: | pH 7.51 | pO2 77 mm Hg | pCO2  32 mm Hg | An ECG last year demonstrated a right axis deviation.

Context: The current chest X-ray showed enlarged pulmonary arteries but no parenchymal inﬁltrates.

Context: A lung perfusion scan revealed a low probability for pulmonary thromboembolism.

Context: The current ECG showed right heart strain but no evidence of primary cardiac disease.

Choices:
A. Echocardiography
B. Holter monitoring
C. Lung biopsy
D. Transbronchial biopsy

Answer: Echocardiography

Pulmonary Disease
General Cardiology
Adult Congenital Heart Disease
Echocardiography

2. Patient complains of dyspnea and mild chest pain on exertion, which increases gradually with continued exertion.

3. Patient had similar symptoms last year.

4. Medical record included arterial blood gas findings of pH 7.51, pO2 77 mm Hg, and pCO2 32 mm Hg.

5. ECG last year demonstrated right axis deviation.

6. Chest X-ray showed enlarged pulmonary arteries but no parenchymal infiltrates.

7. Lung perfusion scan revealed low probability for pulmonary thromboembolism.

8. Current ECG showed right heart strain but no evidence of primary cardiac disease.

2. Her medical record included the following arterial blood gas findings: pH 7.51, pO2 77 mm Hg, pCO2 32 mm Hg

3. An ECG last year demonstrated a right axis deviation

4. The current chest X-ray showed enlarged pulmonary arteries but no parenchymal infiltrates

5. A lung perfusion scan revealed a low probability for pulmonary thromboembolism

6. The current ECG showed right heart strain but no evidence of primary cardiac disease


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

Context: A 4-year-old boy is brought to the physician because of a progressive rash for 2 days.

Context: The rash started behind the ears and now involves the trunk and extremities.

Context: Over the past 4 days, he has had mild sore throat, red, itchy eyes, and headache.

Context: He was born at term and has been healthy except for recurrent episodes of tonsillitis and occasional asthma attacks.

Context: Two weeks ago, he was treated for tonsillitis that resolved with penicillin therapy.

Context: He immigrated with his family from Brazil 3 weeks ago.

Context: His immunization status is unknown.

Context: The patient appears weak and lethargic.

Context: His temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 100/60 mm Hg.

Context: His palms and soles show no abnormalities.

Choices:
A. Rubella
B. Allergic drug reaction
C. Scarlet fever
D. Erythema infectiosum

Answer: Rubella

General Pediatrics
Pediatric Dermatology

2. Patient has had a progressive rash for 2 days.

3. Rash started behind the ears and now involves the trunk and extremities.

4. Patient has had mild sore throat, red, itchy eyes, and headache for 4 days.

5. Patient was born at term and has had recurrent episodes of tonsillitis and occasional asthma attacks.

6. Patient was treated for tonsillitis 2 weeks ago and it resolved with penicillin therapy.

7. Patient immigrated with his family from Brazil 3 weeks ago.

8. Patient's immunization status is unknown.

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

12. Patient's blood pressure is 100/60 mm Hg.

13. Examination shows postauricular and suboccipital lymphadenopathy.

14. Patient has a non-confluent, pink maculopapular rash over the torso and extremities.

15. Patient's palms and soles show no abnormalities.

2. The rash now involves the trunk and extremities.

3. Over the past 4 days, the patient has had a mild sore throat.

4. Over the past 4 days, the patient has had red, itchy eyes.

5. Over the past 4 days, the patient has had a headache.

7. The patient has been healthy except for recurrent episodes of tonsillitis.

8. The patient has been healthy except for occasional asthma attacks.

9. Two weeks ago, the patient was treated for tonsillitis.

10. The tonsillitis resolved with penicillin therapy.

11. The patient immigrated from Brazil 3 weeks ago.

12. The patient's immunization status is unknown.

13. The patient appears weak and lethargic.

14. The patient's temperature is 38°C (100.4°F).

16. The patient's blood pressure is 100/60 mm Hg.

17. Examination shows postauricular and suboccipital lymphadenopathy.

18. There is a non-confluent, pink maculopapular rash over the torso and extremities.

19. The patient's palms and soles show no abnormalities.


Question: Which of the following should be monitored as the patient continues treatment?

Context: He denies chest pain or palpitations.

Context: The patient is found to be anemic.

Context: A fecal occult blood test is positive, and a colonoscopy is obtained.

Context: He undergoes a partial colectomy and is started on 5-fluorouracil as adjuvant chemotherapy.

Choices:
A. Creatinine
B. Fecal leukocytes
C. Neutrophil count
D. Peak flow

Answer: Neutrophil count

1. A 66-year-old man presents to the office complaining of fatigue.

2. He reports that for the past year he has been experiencing a progressive decrease in energy.

3. This week he began having some difficulty breathing while climbing the stairs.

4. He denies chest pain or palpitations.

5. He has no other chronic medical conditions and has had no prior surgeries.

7. A fecal occult blood test is positive.

9. The patient is subsequently diagnosed with colorectal cancer.

11. He is started on 5-fluorouracil as adjuvant chemotherapy.

1. Patient reports progressive decrease in energy for the past year.

2. Patient began having difficulty breathing while climbing stairs this week.

3. Patient denies chest pain or palpitations.

4. Patient has no other chronic medical conditions.

9. Patient is diagnosed with colorectal cancer.

10. Patient undergoes a partial colectomy.

11. Patient is started on 5-fluorouracil as adjuvant chemotherapy.


Question: The molecular structure of the drug most likely recommended by the physician closely resembles a drug used to treat which of the following conditions?

Context: She has multiple erythematous pustules and nodules over her face, for which she has received erythromycin and topical benzoyl peroxide.

Context: The physician recommends a drug on the condition that the patient agrees to use oral contraceptives.

Choices:
A. EGFR-positive non-small cell lung cancer
B. Acute promyelocytic leukemia
C. BRAF-positive metastatic melanoma
D. Choriocarcinoma

Answer: Acute promyelocytic leukemia

1. A 15-year-old girl comes to the physician for a follow-up evaluation.

2. She has multiple erythematous pustules and nodules over her face.

3. She has received erythromycin and topical benzoyl peroxide.

4. She is concerned that the therapy is ineffective.

6. The patient must agree to use oral contraceptives in order to receive the drug.

1. The patient has multiple erythematous pustules and nodules over her face.

2. The patient has received erythromycin and topical benzoyl peroxide for her condition.

3. The patient is concerned that the therapy is ineffective.

4. The physician recommends a drug for the patient.

5. The physician's recommendation is conditional on the patient agreeing to use oral contraceptives.


Question: A biopsy of one of this lesion would most likely reveal which of the following?

Context: A 62-year-old female presents to her primary care provider complaining of a mass near her right jaw.

Context: She reports that the mass is painless and has grown very slowly over the past six months.

Context: However, she reports that she noticed some right-sided facial weakness in the past week which prompted her to visit the physician.

Context: Her past medical history is notable for Hodgkins lymphoma as a child which required radiation therapy to the neck.

Context: She has a 20 pack-year smoking history and drinks alcohol socially.

Context: Her temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 85/min, and respirations are 18/min.

Choices:
A. Cystic configurations of anaplastic squamous and mucoid cells
B. Non-infiltrative clusters of epithelial and mesenchymal cells
C. Epithelial cells with dense lymphoid stroma and germinal centers
D. Uniform spindle cells with scant cytoplasm and cigar-shaped nuclei

Answer: Cystic configurations of anaplastic squamous and mucoid cells

2. Patient presents with a mass near her right jaw.

3. Mass is painless and has grown slowly over the past six months.

4. Patient initially did not see a physician due to being very busy at her work as a lawyer.

5. Patient noticed some right-sided facial weakness in the past week which prompted her to visit the physician.

6. Patient's past medical history is notable for Hodgkins lymphoma as a child which required radiation therapy to the neck.

7. Patient has a 20 pack-year smoking history.

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

10. Patient's blood pressure is 120/85 mmHg.

13. Physical examination reveals a painless firm mass at the angle of the right jaw.

14. Physical examination reveals a small palpable firm mass beneath the floor of the mouth.

15. Physical examination reveals a right facial droop along with an inability to elevate her right eyebrow.

2. The mass has grown very slowly over the past six months.

3. She initially did not see a physician due to being very busy at her work as a lawyer.

4. She noticed some right-sided facial weakness in the past week.

5. Her past medical history is notable for Hodgkins lymphoma as a child.

6. The Hodgkins lymphoma required radiation therapy to the neck.

7. She has a 20 pack-year smoking history.

14. There is also a small palpable firm mass beneath the floor of the mouth.

15. A right facial droop along with an inability to elevate her right eyebrow is noted.


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

Context: A 29-year-old woman presents with low-grade fever, rash, and joint pain.

Context: She says her symptoms started gradually about 3 months ago and have progressively worsened.

Context: The patient describes her rash as pruritic, flat, and localized to her face.

Context: She reports a different type of rash on her shoulders and arms that are aggravated by exposure to sunlight.

Context: She describes her joint pain as moderate, dull and aching in character, and present mainly in the small bones of her wrists and hands, worse on the right than the left.

Context: She has no other relevant medical history and takes no current medications.

Context: Her family history is notable for her maternal grandmother, who had an unknown autoimmune condition.

Context: The patient denies any smoking history, alcohol use, or recreational drug use.

Context: Her temperature is 38.0℃ (100.3℉), pulse is 59/min, respiratory rate is 19/min, and blood pressure is 129/84 mm Hg.

Context: On physical examination, there is a macular, erythematous rash that involves both cheeks and the bridge of her nose, sparing the nasolabial folds.

Context: There is also a mild macular rash on the sun-exposed areas of her upper extremities and shoulders.

Context: She has moderate to severe point tenderness in the small joints of her wrists and hands, worse on the right, with minimal erythema and swelling.

Choices:
A. Swelling and proliferation of endothelial and mesangial cells in portions of each glomerulus with neutrophil infiltration
B. Immunologically mediated destruction of the salivary glands
C. Abnormal accumulation of fibrous tissue in the skin and multiple organs
D. Amyloid deposits within the myocardium between the muscle fibers

Answer: Swelling and proliferation of endothelial and mesangial cells in portions of each glomerulus with neutrophil infiltration

2. Patient has low-grade fever, rash, and joint pain.

3. Symptoms started gradually about 3 months ago and have progressively worsened.

4. Rash is pruritic, flat, and localized to her face.

5. Different type of rash on her shoulders and arms that are aggravated by exposure to sunlight.

6. Joint pain is moderate, dull and aching in character, and present mainly in the small bones of her wrists and hands, worse on the right than the left.

7. No other relevant medical history and takes no current medications.

8. Family history is notable for her maternal grandmother, who had an unknown autoimmune condition.

9. Patient denies any smoking history, alcohol use, or recreational drug use.

14. Physical examination reveals macular, erythematous rash that involves both cheeks and the bridge of her nose, sparing the nasolabial folds.

15. Mild macular rash on the sun-exposed areas of her upper extremities and shoulders.

16. Moderate to severe point tenderness in the small joints of her wrists and hands, worse on the right, with minimal erythema and swelling.

17. Multiple painless ulcers are present on the soft and hard palate.

1. Symptoms started gradually about 3 months ago

3. Rash is pruritic, flat, and localized to her face

4. Different type of rash on shoulders and arms aggravated by sunlight

5. Joint pain is moderate, dull, and aching in character

6. Joint pain mainly in the small bones of wrists and hands, worse on the right

9. Family history notable for maternal grandmother with an unknown autoimmune condition

10. Denies smoking history, alcohol use, or recreational drug use

15. Macular, erythematous rash involves both cheeks and the bridge of her nose, sparing the nasolabial folds

16. Mild macular rash on the sun-exposed areas of her upper extremities and shoulders

17. Moderate to severe point tenderness in the small joints of her wrists and hands, worse on the right, with minimal erythema and swelling

18. Multiple painless ulcers present on the soft and hard palate


Question: The child likely has:

Context: A 3-year-old Cuban-American male has a history of recurrent Pseudomonas and Candida infections.

Context: Examination of his serum shows decreased levels of IgG and CT scan reveals the absence of a thymus.

Choices:
A. Severe combined immunodeficiency syndrome
B. DiGeorge syndrome
C. Isolated IgA deficiency
D. Common variable immunodeficiency

Answer: Severe combined immunodeficiency syndrome

Immunology
Immunology and Allergy
General Allergy and Immunology

1. Patient is a 3-year-old Cuban-American male.

2. Patient has a history of recurrent Pseudomonas and Candida infections.

3. Laboratory analysis reveals no electrolyte abnormalities.

4. Examination of patient's serum shows decreased levels of IgG.

5. CT scan reveals the absence of a thymus.

1. Laboratory analysis reveals no electrolyte abnormalities.

2. Examination of his serum shows decreased levels of IgG.

3. CT scan reveals the absence of a thymus.


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

Context: Her pulse is 89/min and blood pressure is 117/92 mm Hg.

Context: Laboratory studies show: | Platelet count 100,000/mm3 | Prothrombin time 12 seconds | Partial thromboplastin time 33 seconds | Bleeding time 13 minutes | A peripheral blood smear shows enlarged platelets.

Choices:
A. Glycoprotein Ib deficiency
B. Vitamin K deficiency
C. Von Willebrand factor deficiency
D. ADAMTS13 deficiency

Answer: Glycoprotein Ib deficiency

1. A 7-year-old girl is brought to the physician for evaluation of recurrent epistaxis.

2. Her mother reports that she bruises easily while playing.

5. Examination shows multiple bruises in the upper and lower extremities.

6. Laboratory studies show a platelet count of 100,000/mm3.

8. Partial thromboplastin time is 33 seconds.

10. A peripheral blood smear shows enlarged platelets.

11. Ristocetin assay shows no platelet aggregation.

1. Her mother reports that she bruises easily while playing.

4. Examination shows multiple bruises in the upper and lower extremities.

7. Partial thromboplastin time is 33 seconds.

9. A peripheral blood smear shows enlarged platelets.

10. Ristocetin assay shows no platelet aggregation.


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

Context: A 38-year-old woman comes to the emergency department because of progressive headache, blurry vision, and nausea for 1 day.

Context: She appears lethargic.

Context: Her temperature is 39.1°C (102.3°F), and blood pressure is 148/95 mm Hg.

Choices:
A. Cerebral venous thrombosis
B. Hypertensive emergency
C. Subarachnoid hemorrhage
D. Viral meningitis

Answer: Cerebral venous thrombosis

Neurology with Special Qualification in Child Neurology

1. A 38-year-old woman comes to the emergency department.

2. She has progressive headache, blurry vision, and nausea for 1 day.

3. Four days ago, she was diagnosed with a right middle ear infection.

7. Ophthalmologic examination shows bilateral swelling of the optic disc.

8. The corneal reflex in the right eye is absent.

9. Sensation to touch is reduced on the upper right side of the face.

10. Serum studies show increased concentrations of fibrin degradation products.

1. Four days ago, she was diagnosed with a right middle ear infection.

5. Ophthalmologic examination shows bilateral swelling of the optic disc.

6. The corneal reflex in the right eye is absent.

7. Sensation to touch is reduced on the upper right side of the face.

8. Serum studies show increased concentrations of fibrin degradation products.