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

Context: A 32-year-old G2P2 woman gives birth to a boy at 39 weeks gestation.

Context: The mother recently immigrated from Somalia and had no prenatal care.

Context: She refused all intrapartum medications.

Context: His height and weight were in the 20th and 15th percentiles, respectively.

Context: However, 7 days later, the mother presents to the pediatrician because she noticed redness and discharge in her baby's eyes.

Context: His temperature is 98.8°F (37.1°C), blood pressure is 105/65 mmHg, pulse is 120/min, and respirations are 22/min.

Context: On exam, the boy has scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia.

Choices:
A. Intravenous acyclovir
B. Oral and topical erythromycin
C. Sterile lubricant with artificial tear preparation
D. Topical bacitracin

Answer: Oral and topical erythromycin

General Obstetrics and Gynecology
Maternal

1. A 32-year-old G2P2 woman gave birth to a boy.

3. The mother recently immigrated from Somalia.

5. The mother refused all intrapartum medications.

6. The boy's Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.

7. The boy's height was in the 20th percentile.

8. The boy's weight was in the 15th percentile.

9. Mother and child were discharged the day after birth.

10. Seven days later, the mother presented to the pediatrician.

11. The mother noticed redness and discharge in her baby's eyes.

12. The boy's temperature was 98.8°F (37.1°C).

13. The boy's blood pressure was 105/65 mmHg.

16. On exam, the boy had scant non-purulent mucoid bilateral eye discharge and conjunctival hyperemia.

1. The mother recently immigrated from Somalia.

3. The mother refused all intrapartum medications.

4. The boy’s Apgar scores were 7 and 9 at 1 and 5 minutes, respectively.

5. The boy’s height was in the 20th percentile.

6. The boy’s weight was in the 15th percentile.

7. Mother and child were discharged the day after birth.

8. 7 days later, the mother presents to the pediatrician.

9. The mother noticed redness and discharge in her baby's eyes.

10. The boy's temperature is 98.8°F (37.1°C).

11. The boy's blood pressure is 105/65 mmHg.

14. On exam, the boy has scant non-purulent mucoid bilateral eye discharge.

15. On exam, the boy has conjunctival hyperemia.


Question: Inhibition of which of the following processes is the best explanation for such adverse effects?

Context: A 21-year-old woman presents to her physician for a regular follow-up visit.

Context: She was diagnosed with relapsing-remitting multiple sclerosis 2 months ago when she suffered a second episode of optic neuritis.

Context: She was successfully treated with methylprednisolone pulse therapy and discharged.

Context: Today, she only complains of slight fatigue with upper and lower extremity weakness.

Context: Her blood pressure is 120/80 mm Hg, her heart rate is 63/min, her respiratory rate is 14/min, and her temperature is 36.7°C (98.0°F).

Context: She is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections.

Choices:
A. Tight adhesion of leukocytes to the endothelial cells
B. Expression of selectins on the surface of endothelial cells
C. Formation of tight bounds between leukocytes and endothelial selectins
D. Inhibition of interaction between platelet endothelial cell adhesion molecules (PECAMs) on the surfaces of leukocytes and endothelial cells

Answer: Tight adhesion of leukocytes to the endothelial cells

2. Patient was diagnosed with relapsing-remitting multiple sclerosis 2 months ago.

3. Patient suffered a second episode of optic neuritis.

4. Patient was successfully treated with methylprednisolone pulse therapy and discharged.

5. Patient only complains of slight fatigue with upper and lower extremity weakness.

6. Patient's blood pressure is 120/80 mm Hg.

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

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

10. Neurological examination reveals brisk deep reflexes (3+ equal).

11. Neurological examination reveals decreased strength (4/4) in the upper limbs.

12. The rest of the examination is unremarkable.

13. Patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.

14. Patient is concerned about the side effects of this drug, among which is increased susceptibility to the upper respiratory tract and urinary tract infections.

1. The patient was diagnosed with relapsing-remitting multiple sclerosis 2 months ago.

2. The diagnosis was made after she suffered a second episode of optic neuritis.

3. She was treated with methylprednisolone pulse therapy and discharged.

4. Currently, she complains of slight fatigue with upper and lower extremity weakness.

9. Neurological examination reveals brisk deep reflexes (3+ equal) and decreased strength (4/4) in the upper limbs.

10. The rest of the examination is unremarkable.

11. The patient is prescribed a drug that is an inhibitor of ɑ4-integrin (CD49d) for the prevention of relapses.

12. The patient is concerned about the side effects of the drug, including increased susceptibility to upper respiratory tract and urinary tract infections.


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

Context: A 64-year-old man presents to the clinic complaining of low back pain.

Context: He was diagnosed with benign prostatic hypertrophy several years ago, which worsened last year.

Context: A hard nodule was felt on a digital rectal exam, which led to a prostate biopsy that revealed high-grade adenocarcinoma.

Context: A bone scan at that time showed small, focal abnormalities in the lumbar spine.

Context: He subsequently underwent radiation therapy to his prostate and pelvic lymph nodes.

Context: He was then placed on leuprolide and an anti-androgen.

Context: He was doing well until 2 months ago when he developed low back pain, which has worsened since then.

Context: He reports that the pain is 8/10 and nearly constant.

Context: He states that the pain not only affects his ability to fall asleep but also wakes him up at night.

Context: The pain is mildly alleviated by ibuprofen.

Context: In addition to prostate cancer, his medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.

Context: He takes aspirin, lisinopril, rosuvastatin, and pantoprazole.

Context: Upon physical examination, there is midline tenderness within the lumbar region.

Context: Magnetic resonance imaging of the spine is obtained, which shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.

Context: His prostate-specific antigen is 17.5 ng/mL.

Choices:
A. Calcium and vitamin D supplementation
B. External radiation therapy
C. Flutamide
D. Kyphoplasty

Answer: External radiation therapy

3. Patient was diagnosed with benign prostatic hypertrophy several years ago.

4. Benign prostatic hypertrophy worsened last year.

5. Digital rectal exam revealed a hard nodule.

6. Prostate biopsy revealed high-grade adenocarcinoma.

7. Bone scan showed small, focal abnormalities in the lumbar spine.

8. Patient underwent radiation therapy to prostate and pelvic lymph nodes.

9. Patient was placed on leuprolide and an anti-androgen.

10. Patient was doing well until 2 months ago.

11. Low back pain has worsened since then.

13. Pain affects patient's ability to fall asleep and wakes him up at night.

14. Pain is mildly alleviated by ibuprofen.

15. Patient's medical history is significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease.

16. Patient takes aspirin, lisinopril, rosuvastatin, and pantoprazole.

17. Physical examination reveals midline tenderness within the lumbar region.

18. Magnetic resonance imaging of the spine shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression.

19. Patient's prostate-specific antigen is 17.5 ng/mL.

1. Diagnosed with benign prostatic hypertrophy several years ago

3. Hard nodule felt on digital rectal exam

4. Prostate biopsy revealed high-grade adenocarcinoma

5. Bone scan showed small, focal abnormalities in the lumbar spine

6. Underwent radiation therapy to prostate and pelvic lymph nodes

7. Placed on leuprolide and an anti-androgen

10. Pain affects ability to fall asleep and wakes him up at night

12. Medical history significant for hypertension, hyperlipidemia, recurrent nephrolithiasis, and gastroesophageal reflux disease

13. Takes aspirin, lisinopril, rosuvastatin, and pantoprazole

14. Midline tenderness within the lumbar region upon physical examination

15. Magnetic resonance imaging shows bony metastasis to the L2 and L3 spine without evidence of fracture or spinal cord compression

16. Prostate-specific antigen is 17.5 ng/mL


Question: Which of the following is the most likely cause of her current condition?

Context: Two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident, a 34-year-old woman develops sudden shortness of breath.

Context: Her temperature is 38.3°C (100.9°F), pulse is 122/min, respiratory rate is 31/min, and blood pressure is 152/90 mm Hg.

Context: Her hemoglobin concentration is 10.3 g/dL, leukocyte count is 9,500/mm3, and platelet count is 140,000/mm3.

Choices:
A. Fat globules entering the circulation
B. Rupture of a coronary plaque
C. Damage to the alveolar capillary endothelium
D. Bacterial invasion of the pulmonary parenchyma

Answer: Fat globules entering the circulation

1. A 34-year-old woman developed sudden shortness of breath two days after undergoing internal fixation of a displaced right femoral fracture sustained during a motor vehicle accident.

2. On examination, she is oriented only to person.

7. Pulse oximetry on room air shows an oxygen saturation of 83%.

8. There are several scattered petechiae on the anterior chest wall.

9. Her hemoglobin concentration is 10.3 g/dL.

1. On examination, she is oriented only to person.

6. Pulse oximetry on room air shows an oxygen saturation of 83%.

7. There are several scattered petechiae on the anterior chest wall.

8. Her hemoglobin concentration is 10.3 g/dL.


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

Context: A 15-year-old girl comes to the physician for the evaluation of a painless swelling under the left lower jaw for 5 months.

Context: Her 18-year-old sister has a history of acute lymphoblastic leukemia that has been in remission for 11 years.

Context: The patient's temperature is 37°C (98.6°F) Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

Context: The swelling is soft and fluctuant.

Context: It does not move with swallowing, and forced exhalation against a closed glottis does not increase the size of the swelling.

Choices:
A. Lymphadenopathy
B. Branchial cleft cyst
C. Laryngocele
D. Infantile hemangioma

Answer: Branchial cleft cyst

2. Patient has a painless swelling under the left lower jaw for 5 months.

3. Patient's 18-year-old sister has a history of acute lymphoblastic leukemia in remission for 11 years.

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

5. Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

7. Swelling does not move with swallowing.

8. Forced exhalation against a closed glottis does not increase the size of the swelling.

9. Ultrasound shows a round mass with uniform low echogenicity and no internal septations.

1. Her 18-year-old sister has a history of acute lymphoblastic leukemia.

2. The sister's leukemia has been in remission for 11 years.

3. The patient's temperature is 37°C (98.6°F).

4. Physical examination shows a 3 × 2 cm swelling on the left side, 4 cm below the base of the mandible and anterior to the sternocleidomastoid muscle.

6. The swelling does not move with swallowing.

7. Forced exhalation against a closed glottis does not increase the size of the swelling.

8. Ultrasound shows a round mass with uniform low echogenicity and no internal septations.


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

Context: A 70-year-old man is brought to the emergency department by staff of the group home where he resides because of fever, a productive cough, and blood-tinged sputum for 2 days.

Context: The staff report that he developed myalgia, headache, and rhinorrhea 7 days ago, which improved initially before worsening again.

Context: Current medications include enalapril and donepezil.

Context: On arrival, he is obtunded.

Context: His temperature is 39.8°C (103.6°F), pulse is 120/min, respirations are 22/min and shallow, and blood pressure is 100/60 mm Hg.

Context: An x-ray of the chest shows bilateral lung opacities and multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.

Choices:
A. Infection with Staphylococcus aureus
B. Infection with Aspergillus fumigatus
C. Foreign body aspiration
D. Granulomatosis with polyangiitis

Answer: Infection with Staphylococcus aureus

Pulmonary Disease
General Pulmonary Disease

1. A 70-year-old man is brought to the emergency department.

3. He has fever, a productive cough, and blood-tinged sputum for 2 days.

4. He developed myalgia, headache, and rhinorrhea 7 days ago.

5. His symptoms initially improved before worsening again.

6. He has hypertension and Alzheimer disease.

7. His current medications include enalapril and donepezil.

11. His respirations are 22/min and shallow.

13. Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.

14. Examination shows scattered crackles and rhonchi throughout both lung fields.

15. An x-ray of the chest shows bilateral lung opacities.

16. An x-ray of the chest shows multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.

1. He developed myalgia, headache, and rhinorrhea 7 days ago.

2. His symptoms improved initially before worsening again.

5. His current medications include enalapril and donepezil.

9. His respirations are 22/min and shallow.

11. Pulse oximetry on 10 L/min of oxygen via nasal cannula shows an oxygen saturation of 92%.

12. Examination shows scattered crackles and rhonchi throughout both lung fields.

13. An x-ray of the chest shows bilateral lung opacities.

14. An x-ray of the chest shows multiple small, thin-walled cystic spaces within the basal pulmonary parenchyma.


Question: Which of the following is the most likely infectious agent?

Context: A 55-year-old man presents to his primary care physician with ear pain.

Context: The patient states he has had worsening ear pain for the past 2 days.

Context: He describes his pain as 9/10.

Context: His current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin.

Context: His temperature is 100.5°F (38.1°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 98% on room air.

Choices:
A. Haemophilus influenzae
B. Moraxella catarrhalis
C. Pseudomonas aeruginosa
D. Staphylococcus aureus

Answer: Pseudomonas aeruginosa

4. Patient has past medical history of diabetes, obesity, and hypertension.

5. Patient is taking insulin, metformin, lisinopril, aspirin, and atorvastatin.

6. Patient's temperature is 100.5°F (38.1°C).

7. Patient's blood pressure is 177/99 mmHg.

10. Patient's oxygen saturation is 98% on room air.

11. Physical exam reveals purulent drainage from ear canal.

12. Manipulation of ear causes severe pain.

1. The patient has had worsening ear pain for the past 2 days.

2. The patient describes his pain as 9/10.

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

4. The patient's current medications include insulin, metformin, lisinopril, aspirin, and atorvastatin.

5. The patient's temperature is 100.5°F (38.1°C).

6. The patient's blood pressure is 177/99 mmHg.

8. The patient's respirations are 19/min.

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

10. Physical exam reveals a purulent drainage from the ear canal.

11. Manipulation of the ear causes severe pain.


Question: How do you respond?

Context: He is afebrile, with a blood pressure of 128/60 mmHg, pulse of 100/min, respirations at 25/min, and SpO2 of 95% on room air.

Context: He exhibits no tremors or myoclonus.

Context: His basic metabolic panel is displayed below: |  | Serum: | Na+: 138 mEq/L | Cl-: 90 mEq/L | K+: 4.0 mEq/L | HCO3-: 20 mEq/L | BUN: 30 mg/dL | Glucose: 100 mg/dL | Creatinine: 0.8 mg/dL |  | An arterial blood gas reveals the following: |  | pH: 7.32 | pCO2: 34 mmHg | pO2: 89 mmHg |  | The girlfriend is concerned that the patient's breathing appears uncomfortable.

Choices:
A. His breathing is concerning for hepatic encephalopathy
B. His breathing suggests that he needs some fluids
C. His breathing suggests that he has major depression disorder
D. You are not his healthcare proxy and I cannot speak to you

Answer: His breathing suggests that he needs some fluids

1. A 19-year-old male college student with no significant medical history presents to the emergency department with altered mental status.

2. His girlfriend said that he drank multiple shots of vodka and gin throughout the weekend and was found slumped on the couch with some vomit on his shirt.

8. His pupils are equal and reactive to light bilaterally.

10. The remainder of the physical exam is unremarkable.

21. The girlfriend is concerned that the patient's breathing appears uncomfortable.

1. The patient drank multiple shots of vodka and gin throughout the weekend.

2. The patient was found slumped on the couch with vomit on his shirt.

4. The patient's blood pressure is 128/60 mmHg.

6. The patient's respirations are at 25/min.

7. The patient's SpO2 is 95% on room air.

8. The patient's pupils are equal and reactive to light bilaterally.

9. The patient exhibits no tremors or myoclonus.

11. The patient's basic metabolic panel shows: Na+: 138 mEq/L, Cl-: 90 mEq/L, K+: 4.0 mEq/L, HCO3-: 20 mEq/L, BUN: 30 mg/dL, Glucose: 100 mg/dL, Creatinine: 0.8 mg/dL.

12. An arterial blood gas reveals: pH: 7.32, pCO2: 34 mmHg, pO2: 89 mmHg.

13. The girlfriend is concerned that the patient's breathing appears uncomfortable.


Question: Which of the following explains these findings?

Context: He takes metformin and insulin NPH.

Context: Today, his blood pressure is 130/80 mm Hg, pulse is 76/min, respiratory rate is 18/min, and temperature is 36.5°C (97.7°F).

Context: On physical exam, he appears obese.

Context: His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally.

Context: A urinalysis reveals  glucose (++), and protein (+++).

Choices:
A. Glomerular hyperfiltration
B. Renal artery stenosis
C. Subendothelial immune-complex deposits
D. Interstitial atrophy

Answer: Glomerular hyperfiltration

1. A 56-year-old man presents to his primary care provider for a check-up.

2. His past medical history is significant for type 2 diabetes mellitus for 20 years and insomnia.

4. Both of his parents died in a car accident several years ago.

5. He smokes a half of a pack of cigarettes every day and drinks 1-2 beers a day and more on the weekends.

6. Today, his blood pressure is 130/80 mm Hg.

8. Today, his respiratory rate is 18/min.

9. Today, his temperature is 36.5°C (97.7°F).

11. His heart has a regular rate and rhythm.

12. His lungs are clear to auscultation bilaterally.

13. A foot exam is performed and is unremarkable.

1. His past medical history includes type 2 diabetes mellitus for 20 years.

2. His past medical history includes insomnia.

5. Both of his parents died in a car accident several years ago.

6. He smokes half a pack of cigarettes every day.

7. He drinks 1-2 beers a day and more on the weekends.

13. His heart has a regular rate and rhythm.

14. His lungs are clear to auscultation bilaterally.

15. A foot exam is performed and is unremarkable.


Question: Treatment with which of the following drugs was most likely initiated in this patient?

Context: A 64-year-old man comes to the physician because of a 1-month history of progressively worsening back pain that wakes him up at night.

Context: Initially, there is an increase in serum testosterone and dihydrotestosterone levels, followed by a sustained decrease in both serum hormone levels.

Choices:
A. Leuprolide
B. Finasteride
C. Ketoconazole
D. Cyproterone acetate

Answer: Leuprolide

General Orthopaedic Surgery
Orthopaedic Sports Medicine

1. A 64-year-old man comes to the physician.

2. He has a 1-month history of progressively worsening back pain that wakes him up at night.

3. He also reports symptoms of urinary urgency and a weak urine stream.

4. He has no history of serious illness and takes no medications.

5. Rectal examination shows an enlarged and hardened prostate with a nodular surface.

6. After further evaluation and confirmation of the diagnosis, he is started on a new drug.

7. Initially, there is an increase in serum testosterone and dihydrotestosterone levels.

8. This is followed by a sustained decrease in both serum hormone levels.

1. Patient reports symptoms of urinary urgency

2. Patient reports symptoms of a weak urine stream

3. Patient has no history of serious illness

5. Rectal examination shows an enlarged prostate

6. Rectal examination shows a hardened prostate

7. Rectal examination shows a nodular surface of the prostate

9. Initially, there is an increase in serum testosterone levels

10. Initially, there is an increase in dihydrotestosterone levels

11. There is a sustained decrease in serum testosterone levels

12. There is a sustained decrease in dihydrotestosterone levels


Question: The toxin responsible for this clinical presentation has a mechanism of action that is most similar to which other toxin?

Context: A 46-year-old man presents to a physician three days after arriving in Morocco.

Context: He endorses acute onset of painless, profuse watery diarrhea that appears white and cloudy.

Context: On physical exam, the patient has dry mouth, decreased skin turgor, and cold clammy skin.

Choices:
A. Diphtheria toxin
B. Exotoxin A
C. Edema toxin
D. Shiga-like toxin

Answer: Edema toxin

1. A 46-year-old man presents to a physician.

2. He arrived in Morocco three days ago.

3. He has acute onset of painless, profuse watery diarrhea.

4. The diarrhea appears white and cloudy.

5. The patient denies bloody stool, vomiting, or subjective fevers.

13. His peripheral pulse is rapid and thready.

1. The patient endorses acute onset of painless, profuse watery diarrhea.

2. The diarrhea appears white and cloudy.

3. The patient denies bloody stool, vomiting, or subjective fevers.

4. Vital signs are T 98.6, HR 120, RR 17, and BP 85/50.

5. On physical exam, the patient has dry mouth.

6. The patient has decreased skin turgor.

8. His peripheral pulse is rapid and thready.


Question: What test will most likely be positive?

Context: A 25-year-old woman presents to the urgent care center with a one month history of intermittent chest pain that occurs about 2-3 times per week in the early mornings.

Context: She does not smoke and has never suffered from chest pain before.

Context: She has no family history of early MI.

Choices:
A. Ergonovine
B. Immediately repeat ECG
C. Exercise stress test
D. Kehr's sign

Answer: Ergonovine

1. A 25-year-old woman presents to the urgent care center.

2. She has a one month history of intermittent chest pain.

3. The chest pain occurs about 2-3 times per week in the early mornings.

5. She has never suffered from chest pain before.

6. She has no family history of early MI.

7. A 12 lead ECG does not show any abnormalities.

8. Creatine kinase and troponin I enzymes are within normal limits.

2. She has never suffered from chest pain before.

3. She has no family history of early MI.

4. A 12 lead ECG does not show any abnormalities.

5. Creatine kinase enzymes are within normal limits.

6. Troponin I enzymes are within normal limits.


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

Context: In the operating room, he is placed on continuous hemodynamic monitoring and anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.

Context: His temperature is 37.1°C (98.8°F), pulse is 38/min, respirations are 24/min, and palpable systolic blood pressure is 58 mmHg.

Context: The skin is diaphoretic and flushed.

Context: The lungs are clear to auscultation.

Context: Heart sounds are not audible.

Choices:
A. Loss of sympathetic vascular tone
B. Obstructive thrombus in the pulmonary artery
C. Intravascular volume depletion
D. Type I hypersensitivity reaction

Answer: Loss of sympathetic vascular tone

General Plastic Surgery
Micrographic Dermatologic Surgery

1. A 28-year-old man is scheduled for skin grafting of the right leg.

2. Four weeks earlier, he underwent open reduction and internal fixation of an open right tibial fracture.

3. The postoperative period at that time was complicated by necrosis of the overlying skin.

4. In the operating room, he is placed on continuous hemodynamic monitoring.

5. Anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace.

6. Thirty minutes later, he has severe shortness of breath and lightheadedness and loses consciousness.

10. Palpable systolic blood pressure is 58 mmHg.

11. The skin is diaphoretic and flushed.

12. He withdraws the upper extremities to painful stimuli above the navel.

13. The lungs are clear to auscultation.

1. Four weeks earlier, open reduction and internal fixation of an open right tibial fracture

2. Postoperative period complicated by necrosis of the overlying skin

3. Placed on continuous hemodynamic monitoring in the operating room

4. Anesthetized with intrathecal bupivacaine injected into the L3–L4 spinal interspace

5. Thirty minutes later, severe shortness of breath and lightheadedness

12. Withdraws upper extremities to painful stimuli above the navel


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

Context: A 42-year-old man with no significant medical history presents to the emergency department with complaints of headache, nausea, and dizziness.

Context: He states that he was at home working on his car when he started to feel dizzy and experienced a headache.

Context: This progressed to him feeling nauseous.

Context: The patient states he went inside and drank some water and felt better; however, when he started working on his car again his symptoms returned.

Context: Upon presentation, he states his symptoms have mostly improved except for a persistent headache.

Context: His temperature is 98.1°F (36.7°C), blood pressure is 125/84 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: Neurologic exam is unremarkable.

Choices:
A. 100% oxygen
B. CT
C. Hydroxocobalamin
D. Ibuprofen and acetaminophen

Answer: 100% oxygen

2. Patient has no significant medical history.

3. Patient presented to the emergency department with complaints of headache, nausea, and dizziness.

4. Patient was at home working on his car when he started to feel dizzy and experienced a headache.

5. Symptoms progressed to feeling nauseous.

6. Patient went inside and drank some water and felt better.

7. Symptoms returned when patient started working on his car again.

8. Upon presentation, patient states his symptoms have mostly improved except for a persistent headache.

9. Patient's temperature is 98.1°F (36.7°C).

10. Patient's blood pressure is 125/84 mmHg.

13. Patient's oxygen saturation is 98% on room air.

1. The patient was at home working on his car when he started to feel dizzy and experienced a headache.

2. His symptoms progressed to feeling nauseous.

3. After drinking water, he felt better, but his symptoms returned when he resumed working on his car.

4. Upon presentation, his symptoms had mostly improved except for a persistent headache.

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

10. His neurologic exam is unremarkable.


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

Context: A 19-year-old woman comes to the physician because of severe headaches for the past 3 months.

Context: The headaches are pulsating in nature and she describes the pain as 8 out of 10 in intensity.

Context: She has visited the emergency department for headaches twice in the past month; during both visits, her blood pressure was elevated.

Context: She has polycystic ovarian disease.

Context: She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb); BMI is 32.8 kg/m2.

Context: Her temperature is 37°C (98.6°F), pulse is 99/min, and blood pressure is 168/98 mm Hg.

Context: Examination shows hirsutism.

Context: The abdomen is soft and nontender.

Choices:
A. Combination therapy with captopril and valsartan
B. Percutaneous transluminal angioplasty without stent placement
C. Ramipril and percutaneous transluminal angioplasty without stent placement
D. Enalapril and aortorenal bypass with a vein graft

Answer: Ramipril and percutaneous transluminal angioplasty without stent placement

2. Patient has had severe headaches for 3 months.

4. Patient describes pain as 8 out of 10 in intensity.

5. Patient has visited the emergency department twice in the past month.

6. Both visits showed elevated blood pressure.

7. Patient has polycystic ovarian disease.

8. Medications include metformin and an oral contraceptive pill.

9. Patient is 162 cm tall and weighs 86 kg.

15. Cardiopulmonary examination shows no abnormalities.

17. Abdominal bruit is heard on the left side.

18. Neurologic examination shows no focal findings.

19. Complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range.

20. Plasma free metanephrines are within the reference range.

21. Abdominal ultrasound shows increased peak systolic velocity in the distal portion of the left renal artery.

22. Contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.

23. CT scan of the brain shows no abnormalities.

1. The headaches are pulsating in nature.

2. She describes the pain as 8 out of 10 in intensity.

3. She has visited the emergency department for headaches twice in the past month.

4. During both visits, her blood pressure was elevated.

6. Her medications include metformin and an oral contraceptive pill.

7. She is 162 cm (5 ft 4 in) tall and weighs 86 kg (190 lb).

13. Cardiopulmonary examination shows no abnormalities.

15. An abdominal bruit is heard on the left side.

16. Neurologic examination shows no focal findings.

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

18. Plasma free metanephrines are within the reference range.

19. An abdominal ultrasound shows an increased peak systolic velocity in the distal portion of the left renal artery.

20. A contrast-enhanced CT scan of the abdomen shows alternating stenosis and dilation in an 8-mm distal segment of the left renal artery with approximately 75% reduction in the diameter of the vessel.

21. A CT scan of the brain shows no abnormalities.


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

Context: A 28-year-old male is found to have 93% HbA, 2% HbF, and 5% HbA2 on hemoglobin electrophoresis.

Choices:
A. Alpha thalassemia major with Hb Bart's
B. Beta-thalassemia minor
C. Beta-thalassemia major
D. Diabetes mellitus

Answer: Beta-thalassemia minor

3. Hemoglobin electrophoresis reveals 93% HbA.

4. Hemoglobin electrophoresis reveals 2% HbF.

5. Hemoglobin electrophoresis reveals 5% HbA2.

1. A 28-year-old male
2. Found to have 93% HbA
3. Found to have 2% HbF
4. Found to have 5% HbA2
5. On hemoglobin electrophoresis


Question: Which of the following is the best assessment of the patient’s capacity to make healthcare decisions?

Context: A 76-year-old female is brought to the emergency department for altered mental status.

Context: She is accompanied by a nurse from her nursing home.

Context: The nurse says that usually the patient is interactive even though she is sometimes forgetful.

Context: In the last two days, the patient has been increasingly lethargic and doesn’t respond to the staff’s questions.

Context: She also has not been able to get up and use the restroom so the staff has had to change multiple soiled sheets.

Context: Her temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min.

Context: She is not oriented to person, place, or time.

Context: Urine culture grows >100,000 CFU of E.

Context: coli.

Choices:
A. The patient does not have capacity to make decisions
B. The patient does have capacity to make decisions
C. The hospital ethics board should be consulted
D. Capacity cannot be determined at this time

Answer: Capacity cannot be determined at this time

3. Patient is accompanied by a nurse from her nursing home.

4. Patient is usually interactive, but sometimes forgetful.

5. Patient has been increasingly lethargic in the last two days.

6. Patient does not respond to staff's questions.

7. Patient has not been able to get up and use the restroom.

8. Staff has had to change multiple soiled sheets.

9. Patient's temperature is 102.1°F (38.9°C).

10. Patient's blood pressure is 100/74 mmHg.

14. Patient can be subdued with reorientation by the care team.

15. Patient is not oriented to person, place, or time.

16. Urinalysis shows positive leukocyte esterase and nitrites.

17. Urine culture grows >100,000 CFU of E. coli.

18. Physician team would like to consent this patient for a Foley catheter.

1. The patient is accompanied by a nurse from her nursing home.

2. The nurse states that the patient is usually interactive but sometimes forgetful.

3. In the last two days, the patient has been increasingly lethargic and unresponsive to staff questions.

4. The patient has not been able to get up and use the restroom, requiring staff to change multiple soiled sheets.

5. The patient's temperature is 102.1°F (38.9°C), blood pressure is 100/74 mmHg, pulse is 120/min, and respirations are 24/min.

6. The patient is combative on arrival but can be subdued with reorientation by the care team.

7. The patient is not oriented to person, place, or time.

8. Urinalysis shows positive leukocyte esterase and nitrites.

9. Urine culture grows >100,000 CFU of E. coli.

10. The physician team would like to consent this patient for a Foley catheter.


Question: While the physician empathizes with the family, which of the following is the most appropriate response?

Context: She has no history of serious illness.

Context: Her Glasgow Coma Scale (GCS) is 3.

Context: Her father is shocked at the suggestion of organ donation and says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!” .

Choices:
A. “Only after your consent will her organs be removed.”
B. “Brain death is considered legal death just as if her heart was not beating.”
C. “She is very unlikely to recover.”
D. “She will be dead once she is disconnected from advanced life-support.”

Answer: “Brain death is considered legal death just as if her heart was not beating.”

1. A 19-year-old woman is brought to the emergency department by ambulance 1 hour after a motor vehicle accident.

2. She has no history of serious illness.

3. She is on mechanical ventilation without any sedation.

4. Her vital signs are within a normal range.

6. Examination by the attending trauma surgeon and neurologist shows brain death.

7. Laboratory studies show no abnormalities.

8. A search on the state donor registry shows that she has registered as an organ donor.

9. Her father is shocked at the suggestion of organ donation.

10. He says that “life is still circulating in her body because it is warm, and she has a normal heartbeat!”

1. She has no history of serious illness.

2. She is on mechanical ventilation without any sedation.

3. Her vital signs are within a normal range.

5. Examination by the attending trauma surgeon and neurologist shows brain death.

6. Laboratory studies show no abnormalities.

7. A search on the state donor registry shows that she has registered as an organ donor.

8. Her father is shocked at the suggestion of organ donation.

9. Her father says that "life is still circulating in her body because it is warm, and she has a normal heartbeat."


Question: Which of the following ego defenses best characterizes this gentleman's behavior?

Choices:
A. Altruism
B. Displacement
C. Sublimation
D. Atonement

Answer: Altruism

1. A 58-year-old male has had long-term involvement in the world of organized crime.

2. He very recently retired from his post within this organization.

3. This former mafia boss has now suddenly started making large contributions to several local charities.

1. He very recently retired from his post within this organization.

2. This former mafia boss has now suddenly started making large contributions to several local charities.


Question: The patient's pulmonary function tests would be similar to that seen in a patient with:

Context: A 45-year-old man presents with a chronic productive cough that he has had for the past few years.

Context: He admits to having smoked 1 pack of cigarettes a day for the past 25 years.

Choices:
A. Asymptomatic asthma
B. Silicosis
C. Emphysema
D. Coal worker's pneumonitis

Answer: Emphysema

1. A 45-year-old man presents with a chronic productive cough.

2. The cough has been present for the past few years.

3. The man has smoked 1 pack of cigarettes a day for the past 25 years.

4. A chest radiograph reveals an enlarged heart.

1. He admits to smoking 1 pack of cigarettes a day for the past 25 years.

2. A chest radiograph reveals an enlarged heart.


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

Choices:
A. Decreased orexin
B. Decreased melatonin
C. Increased dopamine
D. Increased acetylcholine

Answer: Decreased melatonin

1. A 69-year-old gentleman presents to his primary care physician for a general checkup.

2. He states that overall he is doing well.

3. Ever since he retired, he has been working on projects at home, and taking time to exercise every day.

4. He eats a balanced diet, and has been spending time with his wife every evening.

5. Despite this, the patient claims that he feels less well rested when he awakes in the morning.

6. The patient states that he used to sleep nine hours a night in his youth and felt excellent.

7. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.

8. The patient’s wife states that he seems to sleep peacefully.

9. On physical exam the patient’s neurological exam is within normal limits.

10. The patient is muscular and has a healthy weight and has a pleasant demeanor.

11. He denies feeling fatigued or tired currently.

1. The patient states that overall he is doing well.

2. Ever since he retired, he has been working on projects at home.

5. He has been spending time with his wife every evening.

6. The patient claims that he feels less well rested when he awakes in the morning.

7. He used to sleep nine hours a night in his youth and felt excellent.

8. Now he sleeps seven hours a night and doesn’t feel as well rested as he used to.

9. The patient’s wife states that he seems to sleep peacefully.

10. On physical exam, the patient’s neurological exam is within normal limits.

11. The patient is muscular and has a healthy weight.

13. He denies feeling fatigued or tired currently.


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

Context: A 7-year-old boy with sickle cell disease is brought into the clinic by his mother for knee and hip pain.

Context: His temperature is 97.9°F (36.6°C), blood pressure is 84/54 mmHg, pulse is 100/min, respirations are 19/min, and oxygen saturation is 99% on room air.

Context: There is decreased range of motion at the hip and pain with ambulation.

Choices:
A. CT
B. Ibuprofen and acetaminophen
C. MRI
D. Radiograph

Answer: Radiograph

3. Patient is brought into the clinic by his mother.

5. Patient has been admitted several times in the past for pain crises.

6. Patient's pain crises were managed with fluids and hydromorphone.

7. Patient has been complaining of worsening hip pain over the last several days.

9. Patient's temperature is 97.9°F (36.6°C).

10. Patient's blood pressure is 84/54 mmHg.

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

14. On physical exam, the hip appears normal.

15. On physical exam, the hip is cool to the touch.

16. On physical exam, there is decreased range of motion at the hip.

17. On physical exam, there is pain with ambulation.

1. The child has been admitted several times in the past for pain crises managed with fluids and hydromorphone.

2. He started complaining of worsening hip pain over the last several days and now walks with a limp.

7. His oxygen saturation is 99% on room air.

8. On physical exam, the hip appears normal and is cool to the touch.

9. There is decreased range of motion at the hip.


Question: Which of the following is a risk factor for this patient condition?

Context: A 65-year-old asian man presents to his primary care physician because of abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.

Context: His temperature is 37.1°C (98.7°F), blood pressure is 120/80 mm Hg, and pulse is 85/min.

Context: Alpha fetoprotein (AFP) is 500 μg/L.

Choices:
A. Exposure to nitrosamines
B. Cyclophosphamide use
C. Clonorchis sinensis infection
D. Chronic hepatitis C infection

Answer: Chronic hepatitis C infection

1. A 65-year-old Asian man presents to his primary care physician.

2. He has abdominal distension, right upper quadrant (RUQ) abdominal pain, decreased appetite, and weight loss for several weeks.

3. He denies smoking or excess alcohol intake.

7. Physical examination reveals a cachectic man with jaundice, palmar erythema, ascites, and a palpable mass in the RUQ.

8. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.

2. Patient denies excess alcohol intake.

6. Physical examination reveals a cachectic man.

7. Physical examination reveals jaundice.

8. Physical examination reveals palmar erythema.

9. Physical examination reveals ascites.

10. Physical examination reveals a palpable mass in the RUQ.

11. Abdominal ultrasound shows a 3 cm hypoechoic mass in the right lobe of the liver.

12. Alpha fetoprotein (AFP) is 500 μg/L.


Question: What should the physician do in this situation?

Context: A 71-year-old man from Puerto Rico presents to the emergency department with a 2-week history of abdominal pain.

Context: He does not speak much English so his family explains that he has been complaining of intermittent pain that is not associated with any particular actions.

Context: Furthermore, his family is concerned because he has been having weight loss and blood in his stool for 3 months.

Context: The physician explains that there is a concern for colon cancer and that a colonoscopy is required to evaluate his condition further.

Context: The family is afraid that the news will upset the patient so they ask that they be allowed to make healthcare decisions on the patient's behalf.

Choices:
A. Ask the family to translate the plan for the patient and ask for questions
B. Call for a Spanish-speaking interpreter to speak with the patient
C. Respect the family's cultural wishes and not discuss the plan with the patient
D. Speak directly with the patient in English to ascertain their wishes

Answer: Call for a Spanish-speaking interpreter to speak with the patient

1. A 71-year-old man from Puerto Rico presents to the emergency department.

2. He has a 2-week history of abdominal pain.

4. His family explains that he has been complaining of intermittent pain that is not associated with any particular actions.

5. His family is concerned because he has been having weight loss and blood in his stool for 3 months.

6. The physician explains that there is a concern for colon cancer.

7. A colonoscopy is required to evaluate his condition further.

8. The family is afraid that the news will upset the patient.

9. They ask that they be allowed to make healthcare decisions on the patient's behalf.

10. They explain that this is the way that their culture handles medical decisions.

1. The patient does not speak much English.

2. The patient has been complaining of intermittent pain.

3. The pain is not associated with any particular actions.

4. The patient has been experiencing weight loss for 3 months.

5. The patient has been having blood in his stool for 3 months.

6. The physician is concerned about colon cancer.

7. A colonoscopy is required to evaluate the patient's condition further.

8. The family is concerned about upsetting the patient with the news.

9. The family wants to make healthcare decisions on the patient's behalf.

10. The family's culture handles medical decisions in this way.


Question: Which of the following ion channels is dysfunctional in this patient?

Context: A 45-year-old man presents to a physician with recurrent episodes of palpitations over the last 3 months.

Context: The episodes are self-limiting but cause significant distress and discomfort to the patient.

Context: After a detailed electrophysiological workup, the physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels, which primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients.

Choices:
A. Fast sodium channels
B. L-type voltage-gated calcium channels
C. T-type voltage-gated calcium channels
D. Inward rectifier IK1 channels

Answer: L-type voltage-gated calcium channels

1. A 45-year-old man presents to a physician.

2. The patient has had recurrent episodes of palpitations over the last 3 months.

4. The episodes cause significant distress and discomfort to the patient.

5. The physician performs a detailed electrophysiological workup.

6. The physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels.

7. The cardiac ion channels primarily produce the plateau phase of the action potential in cardiac myocytes in healthy patients.

2. The episodes cause significant distress and discomfort to the patient.

3. A detailed electrophysiological workup was performed.

4. The physician concludes that the symptoms occur mainly due to abnormal function of the cardiac ion channels.

5. The abnormal function of the cardiac ion channels primarily produces the plateau phase of the action potential in cardiac myocytes in healthy patients.


Question: An analysis of this patient's cerebral spinal fluid is most likely to show which of the following findings?

Context: A 23-year-old man comes to the physician because of severe daytime sleepiness and random episodes of falling asleep during the day for short periods of time.

Context: He sleeps 6–7 hours at night.

Context: Last week, he suddenly “lost control” of his legs and neck for about 30 seconds after his classmate had told him a joke.

Choices:
A. Decreased orexin-A
B. Increased neuron-specific enolase
C. Increased 14-3-3 protein
D. Anti-ganglioside antibodies

Answer: Decreased orexin-A

1. A 23-year-old man comes to the physician.

3. He has random episodes of falling asleep during the day for short periods of time.

4. When he wakes up from these episodes, he feels refreshed.

6. He reports that sometimes he is unable to move for a few minutes when he first wakes up in the morning.

7. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds.

8. This happened after his classmate had told him a joke.

1. He feels refreshed when he wakes up from these episodes.

3. Sometimes he is unable to move for a few minutes when he first wakes up in the morning.

4. Last week, he suddenly “lost control” of his legs and neck for about 30 seconds.

5. The loss of control occurred after his classmate had told him a joke.


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

Context: A 73-year-old man is brought to the emergency department 30 minutes after he lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.

Context: Examination shows hot, dry skin.

Context: His abdomen is soft and nontender.

Context: An ECG shows a normal sinus rhythm.

Choices:
A. Inadequate hypothalamic response
B. Metabolic acidosis with ketosis
C. Elevation of serum thyroxine levels
D. Central dopamine receptor blockade

Answer: Inadequate hypothalamic response

1. A 73-year-old man was brought to the emergency department.

2. He lost consciousness for 5 minutes while watching a game of summer league football in a seat from the stands in the afternoon.

3. On arrival, he is lethargic and oriented only to person.

4. Three weeks ago, he was treated for hepatitis A.

5. He has type 2 diabetes mellitus and hypothyroidism.

6. Current medications include metformin and levothyroxine.

7. His temperature is 41.5 °C (106.7 °F).

12. The pupils are equal and reactive to light.

13. Neurologic examination shows no focal findings.

14. Fundoscopy shows proliferative diabetic retinopathy.

15. Cardiopulmonary examination shows no abnormalities.

17. There is no costovertebral angle tenderness.

18. His serum glucose concentration is 160 mg/dL.

1. On arrival, he is lethargic and oriented only to person.

2. Three weeks ago, he was treated for hepatitis A.

3. He has type 2 diabetes mellitus and hypothyroidism.

4. Current medications include metformin and levothyroxine.

5. His temperature is 41.5 °C (106.7 °F), pulse is 106/min, respirations are 26/min, and blood pressure is 128/70 mm Hg.

7. The pupils are equal and reactive to light.

8. Neurologic examination shows no focal findings.

9. Fundoscopy shows proliferative diabetic retinopathy.

10. Cardiopulmonary examination shows no abnormalities.

12. There is no costovertebral angle tenderness.

13. His serum glucose concentration is 160 mg/dL.


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

Context: A 3-year-old boy is brought to the physician for a well-child examination.

Context: He feels well.

Context: He was born at 38 weeks' gestation and weighed 2766 g (6 lb 2 oz).

Context: He now weighs 14 kg (31 lbs).

Context: There is no personal or family history of serious illness.

Context: His immunizations are up-to-date.

Context: He is at 60th percentile for height and 55th percentile for weight.

Context: Vital signs are within normal limits.

Context: The lungs are clear to auscultation.

Context: A grade 3/6 systolic ejection murmur is heard along the upper left sternal border.

Context: There is a grade 2/6 mid-diastolic murmur along the lower left sternal border.

Context: The abdomen is soft and nontender; there is no organomegaly.

Choices:
A. Patent ductus arteriosus
B. Benign heart murmur
C. Atrial septal defect
D. Pulmonary valve stenosis

Answer: Atrial septal defect

3. Patient was born at 38 weeks' gestation.

4. Patient weighed 2766 g (6 lb 2 oz) at birth.

6. No personal or family history of serious illness.

8. Patient is at 60th percentile for height.

9. Patient is at 55th percentile for weight.

10. Vital signs are within normal limits.

12. Grade 3/6 systolic ejection murmur heard along upper left sternal border.

13. S2 is widely split and does not vary with respiration.

14. Grade 2/6 mid-diastolic murmur heard along lower left sternal border.

2. He weighed 2766 g (6 lb 2 oz) at birth

4. There is no personal or family history of serious illness

10. A grade 3/6 systolic ejection murmur is heard along the upper left sternal border

11. S2 is widely split and does not vary with respiration

12. There is a grade 2/6 mid-diastolic murmur along the lower left sternal border


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

Context: A 30-year-old man presents to the emergency department after being attacked by 2 men a few minutes ago.

Context: He is in apparent distress.

Context: His temperature is 36.8°C (98.2°F), the blood pressure is 100/60 mm Hg, the pulse is 110/min, the respirations are 28/min, and the SaO2 is 85% on 4 L oxygen by nasal cannula.

Choices:
A. Pericardiocentesis
B. Intravenous fluids
C. Dobutamine
D. Needle thoracostomy

Answer: Needle thoracostomy

1. A 30-year-old man presents to the emergency department.

2. He was attacked by 2 men a few minutes ago.

3. He was suddenly approached by 2 men holding knives while he was walking on the street nearby.

4. While trying to escape, he was stabbed once in the neck.

5. He is complaining of difficulty breathing and chest pain.

11. The SaO2 is 85% on 4 L oxygen by nasal cannula.

12. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.

13. The respiratory exam shows severe tenderness in the right chest.

14. The respiratory exam shows decreased inspiration in the right lung.

15. The respiratory exam shows tracheal deviation to the left.

1. He was suddenly approached by 2 men holding knives while walking on the street nearby.

2. While trying to escape, he was stabbed once in the neck.

3. He is complaining of difficulty breathing and chest pain.

9. The SaO2 is 85% on 4 L oxygen by nasal cannula.

10. Examination of the neck reveals a deep penetrating injury on the right side and distended neck veins.

11. The respiratory exam shows severe tenderness in the right chest, decreased inspiration in the right lung, and tracheal deviation to the left.


Question: Which of the following is characteristic of this patient’s diagnosis?

Context: An 8-month-old male presents to your office with a 5-day history of blood in his stool.

Choices:
A. It may affect neonates but is more common in adolescents.
B. It is rare, affecting less than 1% of the population.
C. Both males and females are equally affected.
D. Diagnostic studies localize ectopic gastric tissue.

Answer: Diagnostic studies localize ectopic gastric tissue.

1. An 8-month-old male presents to your office.

2. He has a 5-day history of blood in his stool.

3. Abdominal pain is absent on history obtained from his parents.

4. Past medical history and physical exam findings are not remarkable.

5. Laboratory findings are significant for mild iron deficiency.

1. Abdominal pain is notably absent on history obtained from his parents.

2. Past medical history is not remarkable.

3. Physical exam findings are not remarkable.

4. Laboratory findings are significant for mild iron deficiency.


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

Context: The patient’s mother has become increasingly concerned about him since his high school graduation.

Context: Although she says that he had been an excellent student in high school, his grades have begun slipping in his second year in college, and he no longer socializes with friends.

Context: When she asked him why he no longer talks to his friends, she states that he told her, “They already know where I am.

Context: They can see me.

Context: We don’t need to talk.” She found this to be bizarre, as nearly all of his friends live hours away.

Context: The psychiatrist notices reduced spontaneous movements while the patient is speaking and that he speaks in a monotone with a voice that is soft in volume.

Context: He also appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.

Context: His mood is generally flat with little reactivity or engagement during the course of his interview, but he denies any symptoms of depression or psychosis.

Context: No significant past medical history.

Choices:
A. Paranoid personality disorder
B. Schizophrenia
C. Drug abuse
D. Brain tumor

Answer: Schizophrenia

Child and Adolescent Psychiatry
Schizophrenia

1. A 19-year-old man is brought to a psychiatrist by his mother.

2. His mother has become increasingly concerned about him since his high school graduation.

3. He had been an excellent student in high school.

4. His grades have begun slipping in his second year in college.

5. He no longer socializes with friends.

6. When she asked him why he no longer talks to his friends, he told her, “They already know where I am. They can see me. They watch me from my bedroom window, so they already know what I’m doing. We don’t need to talk.”

7. Nearly all of his friends live hours away.

8. The patient states that he feels fine and doesn’t understand why everyone thinks he is crazy.

9. The psychiatrist notices reduced spontaneous movements while the patient is speaking.

10. He speaks in a monotone with a voice that is soft in volume.

11. He appears suspicious and defensive, asking the psychiatrist “why are you asking me that?” after each evaluative question.

12. His mood is generally flat with little reactivity or engagement during the course of his interview.

13. He denies any symptoms of depression or psychosis.

14. No significant past medical history.

15. Family history is not available as he was adopted.

1. The patient's mother is increasingly concerned about him since his high school graduation.

2. The patient's grades have begun slipping in his second year of college.

3. The patient no longer socializes with friends.

4. The patient told his mother that his friends can see him from his bedroom window and don't need to talk to him.

5. The patient's friends live hours away.

6. The patient feels fine and doesn't understand why everyone thinks he is crazy.

7. The psychiatrist notices reduced spontaneous movements while the patient is speaking.

8. The patient speaks in a monotone with a soft voice.

9. The patient appears suspicious and defensive during the evaluation.

10. The patient's mood is generally flat with little reactivity or engagement.

11. The patient denies any symptoms of depression or psychosis.

12. The patient has no significant past medical history.

13. The patient's family history is not available as he was adopted.


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

Context: A 26-year-old woman comes to the physician because of progressively worsening episodic pelvic pain for 2 years.

Context: Vital signs are within normal limits.

Context: Urine pregnancy test is negative.

Choices:
A. Perform MRI of the pelvis
B. Prescribe gonadotropin-releasing hormone agonists
C. Prescribe androgenic steroids
D. Prescribe estrogen-progestin contraceptives

Answer: Prescribe estrogen-progestin contraceptives

Complex Family Planning
General Obstetrics and Gynecology

2. Patient has had progressively worsening episodic pelvic pain for 2 years.

3. Pain starts a few days before her menstrual period and lasts about 10 days.

4. Patient has tried taking ibuprofen, but her symptoms do not improve.

5. Patient has had regular 29-day menstrual intervals since menarche at the age of 11 years.

7. First day of patient's last menstrual period was 2 weeks ago.

8. Patient is sexually active with her boyfriend.

9. Patient has noticed that intercourse is often painful.

10. Patient and her boyfriend use condoms inconsistently.

11. Vital signs are within normal limits.

12. Pelvic examination shows a normal vagina and cervix.

13. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.

1. The pain starts a few days before her menstrual period and lasts about 10 days.

2. She has tried taking ibuprofen, but her symptoms do not improve.

3. Menses have occurred at regular 29-day intervals since menarche at the age of 11 years and last for 5–7 days.

4. The first day of her last menstrual period was 2 weeks ago.

5. She is sexually active with her boyfriend and has noticed that intercourse is often painful; they use condoms inconsistently.

6. Vital signs are within normal limits.

7. Pelvic examination shows a normal vagina and cervix.

8. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses.


Question: Which of the following will most likely reduce the type II error of this screening test?

Context: A research group has developed a new screening test for HIV that can detect infection 2 weeks earlier than the current gold standard.

Context: A rigorous clinical study of this new screening test involving n subjects yields a false-positive probability α, and a false-negative probability, β.

Choices:
A. Decreasing n
B. Increasing α
C. Increasing the specificity of the test
D. Decreasing the sensitivity of the test

Answer: Increasing α

1. A research group has developed a new screening test for HIV.

2. The new screening test can detect infection 2 weeks earlier than the current gold standard.

3. A rigorous clinical study of the new screening test was conducted involving n subjects.

4. The false-positive probability of the new screening test is α.

5. The false-negative probability of the new screening test is β.

1. A rigorous clinical study was conducted on a new screening test.

3. The study yielded a false-positive probability α.

4. The study yielded a false-negative probability β.


Question: Which of the following is the pathophysiology of this patient's presentation?

Context: A 70-year-old female underwent a right total knee arthroplasty without complication.

Context: She was discharged to a rehab facility on post-operative day 3.

Context: Doppler ultrasound imaging at this time revealed a deep venous thrombosis in the right popliteal and tibial veins.

Context: Five days later, doppler ultrasonography of the lower extremities revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins.

Context: In addition, a thrombus was noted in the left common femoral vein as well.

Choices:
A. Excessive irreversible inactivation of the cyclo-oxygenase enzyme
B. Formation of antibodies to heparin-platelet factor-4 complex
C. Deposition of immune complex nuclear antigens in kidneys
D. Inherited mutation in clotting factor V, which cannot be degraded by activated protein C

Answer: Formation of antibodies to heparin-platelet factor-4 complex

2. Patient underwent right total knee arthroplasty without complication.

3. Patient was discharged to rehab facility on post-operative day 3.

4. Two days after discharge, patient began experiencing pain and swelling of right leg.

5. Doppler ultrasound imaging revealed deep venous thrombosis in right popliteal and tibial veins.

6. Patient was re-admitted and started on unfractionated heparin infusion.

7. Five days later, doppler ultrasonography revealed extension of clot in right lower extremity to include common femoral, superficial femoral, popliteal, tibial, and saphenous veins.

8. Doppler ultrasonography also revealed thrombus in left common femoral vein.

9. CBC showed decrease in platelet count from 195,000/uL on admission to 83,000/uL.

1. The patient was discharged to a rehab facility on post-operative day 3.

2. Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg.

3. Doppler ultrasound imaging revealed a deep venous thrombosis in the right popliteal and tibial veins.

4. The patient was re-admitted and started on an unfractionated heparin infusion.

5. Five days later, doppler ultrasonography revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins.

6. A thrombus was noted in the left common femoral vein as well.

7. CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL.


Question: Which of the following measures would be most effective?

Context: Three days after surgical repair of a distal right radius fracture, a 62-year-old man develops severe wound pain and fever.

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

Context: While treating the patient's condition, the hospital also wants to eradicate the causal pathogen in asymptomatic carriers.

Choices:
A. Permethrin hair wash
B. Colistin nebulized aerosol
C. Chlorhexidine hand disinfection
D. Mupirocin nasal ointment

Answer: Mupirocin nasal ointment

1. A 62-year-old man developed severe wound pain and fever three days after surgical repair of a distal right radius fracture.

2. His temperature was 39.1°C (102.4°F).

3. Physical examination showed erythema and edema of the right arm that extended up to the elbow.

4. Yellow pus drained from the surgical wound.

5. Cultures from the wound fluid grew gram-positive bacteria in grape-like clusters.

6. The bacteria were resistant to nafcillin.

7. The hospital wanted to eradicate the causal pathogen in asymptomatic carriers.

2. Physical examination shows erythema and edema of the right arm that extends up to the elbow.

3. Yellow pus drains from the surgical wound.

4. Cultures from the wound fluid grow gram-positive bacteria in grape-like clusters that are resistant to nafcillin.

5. The hospital wants to eradicate the causal pathogen in asymptomatic carriers while treating the patient's condition.


Question: For this reason (and to accurately answer the research question), the risk of the disease should be estimated in terms of which of the following?

Context: They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors, who were followed up for 4 years in total.

Context: During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group; thus, the risk ratio (RR) of the disease development (exposed vs.

Context: unexposed) was 1.

Context: A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was in fact 0.5 (at 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%; and only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%), a value that deviates from the true RR (i.e.

Choices:
A. Incidence
B. Prevalence
C. Mortality
D. Survival rates

Answer: Incidence

1. A research group from Europe is investigating a potential link between certain lifestyle risk factors and the development of potentially fatal renal disease.

2. They designed a cohort study that included 68 individuals: 34 exposed and 34 unexposed to given risk factors.

3. The study was followed up for 4 years in total.

4. During this time, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group.

5. The risk ratio (RR) of the disease development (exposed vs. unexposed) was 1.

6. During the initial 2 years, there was 1 death in the exposed group, and another death in the unexposed group.

7. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was 0.5.

8. At 2 years of follow-up there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%.

9. There were only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%.

10. The prevalence ratio of 0.5 deviates from the true RR (i.e. 1).

1. A cohort study was designed with 68 individuals: 34 exposed and 34 unexposed to given risk factors.

2. The individuals were followed up for 4 years in total.

3. During the study, the renal disease of interest was seen in 6 individuals among the exposed group and 6 individuals among the unexposed group.

4. The risk ratio (RR) of the disease development (exposed vs. unexposed) was 1.

5. During the initial 2 years, there was 1 death in the exposed group and another death in the unexposed group.

6. A survey administered for the last 2 years of the study showed that the prevalence ratio of disease between exposed and unexposed individuals was 0.5.

7. At 2 years of follow-up, there was only 1 case of the disease in the 34 exposed individuals, with a resulting prevalence of 2.94%.

8. At 2 years of follow-up, there were only 2 cases of the disease in the 34 unexposed individuals, with a resulting prevalence of 5.88%.

9. The prevalence ratio value deviates from the true RR, which is 1.


Question: What is the most likely chromosomal translocation that is responsible for this patient's clinical presentation and lab results?

Context: A 55-year-old male with fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks presents to his family physician.

Context: The patient is referred to an oncologist, and a bone marrow aspiration is performed, demonstrating >20% myeloblasts with Auer rods that are myeloperoxidase positive.

Choices:
A. 15;17
B. 14;18
C. 11;14
D. 8;14

Answer: 15;17

1. A 55-year-old male presents to his family physician.

2. He has had fever, fatigue, generalized weakness, and bleeding gums for the past 3 weeks.

3. On exam, he has bilateral submandibular lymphadenopathy and hepatosplenomegaly.

4. CBC demonstrates decreased RBCs and mature WBCs.

5. The patient is referred to an oncologist.

6. A bone marrow aspiration is performed.

7. The bone marrow aspiration demonstrates >20% myeloblasts with Auer rods.

8. The Auer rods are myeloperoxidase positive.

1. On exam, he has bilateral submandibular lymphadenopathy.

7. The bone marrow aspiration demonstrates >20% myeloblasts.

9. The Auer rods are myeloperoxidase positive.


Question: The patient is most likely experiencing adverse effects caused by a drug that works through which of the following mechanisms of action?

Context: A 59-year-old man with Parkinson disease is brought to the emergency department 1 hour after he had a syncopal episode.

Context: Over the past two weeks, the patient has felt light-headed upon standing and has noticed that his legs have been swollen.

Context: Vital signs show blood pressure 114/70 mm Hg when supine and 92/38 mm Hg upon standing.

Context: Examination of the lower extremities shows a lacy, purple rash and 2+ pitting edema.

Choices:
A. Increased dopamine release from central neurons
B. Inhibition of acetylcholine activity in the basal ganglia
C. Selective inhibition of monoamine oxidase type B
D. Inhibition of central methylation of dopamine

Answer: Increased dopamine release from central neurons

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

2. He had a syncopal episode 1 hour prior.

3. Over the past two weeks, the patient has felt light-headed upon standing.

4. Over the past two weeks, the patient has noticed that his legs have been swollen.

5. He was started on a medication for early symptoms of Parkinson disease one month ago.

6. Vital signs show blood pressure 114/70 mm Hg when supine.

7. Vital signs show blood pressure 92/38 mm Hg upon standing.

8. Examination of the lower extremities shows a lacy, purple rash.

9. Examination of the lower extremities shows 2+ pitting edema.

10. Neurologic examination shows an ataxic gait.

11. The physician decreases the dose of medication.

1. Over the past two weeks, the patient has felt light-headed upon standing.

2. The patient has noticed that his legs have been swollen.

3. The patient was started on a medication for early symptoms of Parkinson disease one month ago.

4. Vital signs show blood pressure 114/70 mm Hg when supine.

5. Vital signs show blood pressure 92/38 mm Hg upon standing.

6. Examination of the lower extremities shows a lacy, purple rash.

7. Examination of the lower extremities shows 2+ pitting edema.

8. Neurologic examination shows an ataxic gait.

9. The physician decreases the dose of medication.


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

Context: Her symptoms have progressively worsened over the course of several months, where she has experienced difficulty getting up from a chair, climbing the stairs, and placing her groceries on the top shelves of her kitchen.

Context: She also reports feeling tired lately and is unsure when this began.

Context: Physical examination is notable for muscle weakness in the deltoids and hip flexors with 2+ biceps, triceps, patellar, and ankle tendon reflexes.

Context: Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L), lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L), and thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL).

Choices:
A. Azathioprine
B. Intravenous immunoglobulin
C. Prednisone
D. Thyroxine

Answer: Prednisone

1. A 50-year-old woman presents to her primary care physician for muscle weakness.

2. Her symptoms have progressively worsened over the course of several months.

3. She has experienced difficulty getting up from a chair.

4. She has experienced difficulty climbing the stairs.

5. She has experienced difficulty placing her groceries on the top shelves of her kitchen.

8. Physical examination is notable for muscle weakness in the deltoids and hip flexors.

9. Biceps, triceps, patellar, and ankle tendon reflexes are 2+.

10. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L.

11. Normal creatine kinase level is 10-70 U/L.

12. Laboratory testing demonstrates a lactate dehydrogenase level of 150 U/L.

13. Normal lactate dehydrogenase level is 45-90 U/L.

14. Laboratory testing demonstrates a thyroid-stimulating hormone level of 1.5 µU/mL.

15. Normal thyroid-stimulating hormone level is 0.5-5.0 µU/mL.

1. The patient's symptoms have progressively worsened over several months.

2. The patient has difficulty getting up from a chair, climbing stairs, and placing groceries on high shelves.

3. The patient reports feeling tired lately and is unsure when this began.

4. Physical examination shows muscle weakness in the deltoids and hip flexors.

5. The patient has 2+ biceps, triceps, patellar, and ankle tendon reflexes.

6. Laboratory testing demonstrates a creatine kinase level of 4,200 U/L (normal is 10-70 U/L).

7. Laboratory testing shows a lactate dehydrogenase level of 150 U/L (normal is 45-90 U/L).

8. Laboratory testing reveals a thyroid-stimulating hormone level of 1.5 µU/mL (normal is 0.5-5.0 µU/mL).


Question: The most likely cause of amenorrhea in this patient is an increase in production of which of the following hormones?"

Context: A 22-year-old woman comes to the physician because of a 5-kg (11-lb) weight gain and hair loss over the past 4 months.

Context: Menarche occurred at the age of 12 years and menses occurred at irregular intervals until she stopped having periods 2 months ago.

Context: She is 165 cm (5 ft 5 in) tall and weighs 82 kg (180 lb); BMI is 30 kg/m2.

Context: Serum studies show: | Thyroid-stimulating hormone 2 μU/mL | Luteinizing hormone 32 mIU/mL | Prolactin 11 ng/mL | Urine pregnancy test is negative.

Choices:
A. Progesterone in corpus luteum
B. Estrogen in adipose tissue
C. Follicle stimulating hormone in the adenohypophysis
D. Dopamine in the hypothalamus

Answer: Estrogen in adipose tissue

1. A 22-year-old woman comes to the physician.

2. She has experienced a 5-kg (11-lb) weight gain and hair loss over the past 4 months.

3. Menarche occurred at the age of 12 years.

4. Menses occurred at irregular intervals until she stopped having periods 2 months ago.

8. Physical examination shows a receding hairline and hair loss over the vertex of the head.

9. Serum studies show: Thyroid-stimulating hormone 2 μU/mL.

10. Serum studies show: Luteinizing hormone 32 mIU/mL.

11. Serum studies show: Prolactin 11 ng/mL.

13. Withdrawal bleeding occurs after a progestin challenge test.

1. Menarche occurred at the age of 12 years.

2. Menses occurred at irregular intervals until she stopped having periods 2 months ago.

6. Physical examination shows a receding hairline.

7. Hair loss is observed over the vertex of the head.

8. Serum studies show: Thyroid-stimulating hormone 2 μU/mL.

9. Serum studies show: Luteinizing hormone 32 mIU/mL.

10. Serum studies show: Prolactin 11 ng/mL.

12. Withdrawal bleeding occurs after a progestin challenge test.


Question: Which of the following drugs was most likely prescribed?

Context: A 70-year-old man with chronic myopia comes to the physician because of a 4-month history of difficulty seeing distant objects, especially at night, despite wearing glasses.

Context: Gonioscopy shows no abnormalities.

Context: He is prescribed a drug.

Context: At a follow-up examination several months later, intraocular pressure is normal, but darkening of the iris and an increase in the length of the eyelashes is observed.

Choices:
A. Timolol
B. Acetazolamide
C. Apraclonidine
D. Latanoprost

Answer: Latanoprost

1. A 70-year-old man has chronic myopia.

2. He has had difficulty seeing distant objects for 4 months, especially at night, despite wearing glasses.

3. Examination shows bilateral narrowing of peripheral visual fields, cupping of the optic discs, and elevated intraocular pressure.

6. At a follow-up examination several months later, intraocular pressure is normal.

7. At the follow-up examination, darkening of the iris is observed.

8. At the follow-up examination, an increase in the length of the eyelashes is observed.

1. Examination shows bilateral narrowing of peripheral visual fields.

2. Examination shows cupping of the optic discs.

3. Examination shows elevated intraocular pressure.

7. At a follow-up examination several months later, darkening of the iris is observed.

8. At a follow-up examination several months later, an increase in the length of the eyelashes is observed.


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

Context: They are concerned because they have on occasion noticed a “swelling of the belly button.” Cord separation occurred at seven days of age.

Context: The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain. |  | .

Choices:
A. Expectant management
B. Histopathologic evaluation
C. Elective surgical management
D. Immediate surgical management

Answer: Expectant management

1. A 3-week-old female presents with her parents to her pediatrician for a routine visit.

2. The parents report that the child is sleeping in regular two-hour intervals and feeding and stooling well.

3. They are concerned because they have on occasion noticed a “swelling of the belly button.”

4. Cord separation occurred at seven days of age.

5. The parents report that the swelling seems to come and go but is never larger than the size of a blueberry.

6. They deny any drainage from the swelling.

7. On physical exam, the child is in no acute distress and appears developmentally appropriate for her age.

8. Her abdomen is soft and non-tender with a soft, 1 cm bulge at the umbilicus.

9. The bulge increases in size when the child cries and can be easily reduced inside the umbilical ring without apparent pain.

1. The child is sleeping in regular two-hour intervals.

2. The child is feeding and stooling well.

3. The parents have noticed a "swelling of the belly button."

5. The swelling seems to come and go but is never larger than the size of a blueberry.

6. There is no drainage from the swelling.

7. On physical exam, the child is in no acute distress.

8. The child appears developmentally appropriate for her age.

10. There is a soft, 1 cm bulge at the umbilicus.

11. The bulge increases in size when the child cries.

12. The bulge can be easily reduced inside the umbilical ring without apparent pain.


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

Context: His temperature is 97.7°F (36.5°C), blood pressure is 94/54 mmHg, pulse is 170/min, respirations are 12/min, and oxygen saturation is 90% on room air.

Context: A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left, and his blood pressure increases to 104/74 mmHg and his pulse decreases to 100/min.

Choices:
A. Chest radiograph
B. Pericardiocentesis
C. Thoracotomy
D. Tube thoracostomy

Answer: Tube thoracostomy

1. A 25-year-old man presents to the emergency department after a motor vehicle collision.

2. He is currently complaining of chest pain and shortness of breath and seems rather confused.

7. His oxygen saturation is 90% on room air.

8. A 14-gauge needle is placed in the 2nd intercostal space on the patient’s left.

9. His blood pressure increases to 104/74 mmHg.

1. The patient is complaining of chest pain and shortness of breath.

3. The patient's temperature is 97.7°F (36.5°C).

4. The patient's blood pressure is 94/54 mmHg.

6. The patient's respirations are 12/min.

7. The patient's oxygen saturation is 90% on room air.

9. The patient's blood pressure increases to 104/74 mmHg after the needle placement.

10. The patient's pulse decreases to 100/min after the needle placement.


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

Context: A 13-year-old girl presents with a rash on her left hand and forearm.

Context: She went hiking with friends the day before yesterday and awoke this morning to find her hand and forearm red and itchy.

Context: She is afebrile and her vital signs are within normal limits.

Context: On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm as shown in the exhibit (see image).

Choices:
A. Oral prednisone
B. Topical clobetasol
C. Phototherapy
D. Azathioprine

Answer: Topical clobetasol

2. Patient went hiking with friends two days ago.

3. Patient awoke this morning with a rash on her left hand and forearm.

4. Patient denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.

5. Patient has no significant past medical history or known allergies.

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

8. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm.

9. Exhibit (see image) shows the rash on the patient's left hand and forearm.

1. She went hiking with friends the day before yesterday.

2. She awoke this morning to find her hand and forearm red and itchy.

3. She denies any swelling of the face or throat, difficulty breathing, dizziness, or palpitations.

4. She has no significant past medical history or known allergies.

6. Her vital signs are within normal limits.

7. On physical examination, there are multiple erythematous papules and fluid-filled vesicles in a linear pattern on her left hand and forearm.


Question: This patient is most likely to die from which of the following complications?

Context: A 12-year-old boy is brought to the physician for multiple bruises.

Context: He has fallen multiple times over the past 4 months and has difficulty walking without assistance.

Context: Neurological examination shows bilateral nystagmus, decreased muscle strength, 1+ reflexes bilaterally, and a wide-based gait with irregular and uneven steps.

Context: His proprioception and vibration senses are absent.

Context: The remainder of the examination shows kyphoscoliosis and foot inversion with hammer toes.

Choices:
A. Renal cell carcinoma
B. Heart failure
C. Posterior fossa tumors
D.
Aspiration pneumonia
"

Answer: Heart failure

1. A 12-year-old boy is brought to the physician.

2. He has fallen multiple times over the past 4 months.

3. He has difficulty walking without assistance.

4. His speech is slow and difficult to understand.

5. Neurological examination shows bilateral nystagmus.

6. Neurological examination shows decreased muscle strength.

7. Neurological examination shows 1+ reflexes bilaterally.

8. Neurological examination shows a wide-based gait with irregular and uneven steps.

9. Neurological examination shows absent proprioception and vibration senses.

10. The remainder of the examination shows kyphoscoliosis.

11. The remainder of the examination shows foot inversion with hammer toes.

1. He has fallen multiple times over the past 4 months.

2. He has difficulty walking without assistance.

3. His speech is slow and difficult to understand.

4. Neurological examination shows bilateral nystagmus.

5. Neurological examination shows decreased muscle strength.

6. Neurological examination shows 1+ reflexes bilaterally.

7. Neurological examination shows a wide-based gait with irregular and uneven steps.


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

Context: A 28-year-old nulligravid woman comes to the physician for a routine health maintenance examination.

Context: Upon questioning, she reports that she and her husband have been trying to conceive for more than 1 year; they have unprotected sexual intercourse 3–4 times per week.

Context: Recently, she has not been enjoying sexual intercourse with her husband because of painful penetration.

Context: She also reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days; she has missed several days of work each month because of the pain.

Context: Menarche was at the age of 13 years, and menses occur at 26–28 day intervals.

Context: There is rectovaginal tenderness.

Choices:
A. Endometrial tisssue within the myometrium on biopsy
B. Multiple bilateral ovarian cysts on ultrasonography
C. Reddish-black peritoneal lesions on laparoscopy
D. Concentric, solid myometrial tumors on MRI

Answer: Reddish-black peritoneal lesions on laparoscopy

3. Patient and her husband have been trying to conceive for more than 1 year.

4. Patient and her husband have unprotected sexual intercourse 3-4 times per week.

5. Patient has not been enjoying sexual intercourse with her husband because of painful penetration.

6. Patient has episodic back and pelvic pain over the past 6 months.

8. Patient has missed several days of work each month because of the pain.

9. Patient's menarche was at the age of 13 years.

10. Patient's menses occur at 26-28 day intervals.

11. Pelvic examination shows a normal-appearing vulva and vagina.

12. Pelvic examination shows rectovaginal tenderness.

13. Ultrasonography of the pelvis shows a retroverted normal-sized uterus.

1. She and her husband have been trying to conceive for more than 1 year.

2. They have unprotected sexual intercourse 3–4 times per week.

3. She has not been enjoying sexual intercourse with her husband because of painful penetration.

4. She reports episodic back and pelvic pain over the past 6 months that lasts for 2–3 days.

5. She has missed several days of work each month because of the pain.

8. Pelvic examination shows a normal-appearing vulva and vagina.

10. Ultrasonography of the pelvis shows a retroverted normal-sized uterus.


Question: What disease is the child suffering from?

Context: A 2-year-old Caucasian male presents with recurrent diaper rash and oral thrush.

Context: He has also experienced recurrent episodes of otitis media from repeat Streptoccous pneumoniae.

Context: He notably has reduced T and B cell counts.

Choices:
A. X-linked agammaglobulinemia
B. Isolated IgA deficiency
C. Severe combined immunodeficiency
D. DiGeorge syndrome

Answer: Severe combined immunodeficiency

Pediatric Immunology
Pediatric Immunology and Allergy
Immunology and Allergy

1. Patient is 2-year-old Caucasian male.

2. Patient presents with recurrent diaper rash and oral thrush.

3. Patient has experienced recurrent episodes of otitis media.

4. Patient has repeat Streptoccous pneumoniae.

5. Patient has reduced T and B cell counts.

1. He has experienced recurrent episodes of otitis media.

2. The otitis media is caused by repeat Streptococcus pneumoniae.


Question: If the pregnancy is continued to term, the child is at an increased risk of developing which of the following conditions?

Context: Her blood pressure is 110/70 mm Hg, a heart rate of 95/min, a respiratory rate of 20/min, and a temperature of 36.4°C (97.5°F).

Context: Physical examination is unremarkable.

Context: Laboratory studies show decreased levels of PAPP-A and increased levels of β-hCG.

Choices:
A. Vaginal adenosis
B. Huntington disease
C. Alzheimer’s disease
D. Ebstein anomaly

Answer: Alzheimer’s disease

1. A 42-year-old primigravida woman presents to her gynecologist for a routine prenatal visit at 11 weeks of gestation.

2. Her pregnancy has been uneventful so far.

3. She denies smoking, using alcohol, or any illicit drugs.

4. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.

9. Physical examination is unremarkable.

10. A transvaginal ultrasound reveals increased nuchal translucency.

11. Laboratory studies show decreased levels of PAPP-A.

12. Laboratory studies show increased levels of β-hCG.

1. Her pregnancy has been uneventful so far.

2. She denies smoking, using alcohol, or any illicit drugs.

3. Past medical history is significant for Hashimoto’s thyroiditis which is well-controlled with levothyroxine.

8. Physical examination is unremarkable.

9. A transvaginal ultrasound reveals increased nuchal translucency.

10. Laboratory studies show decreased levels of PAPP-A.

11. Laboratory studies show increased levels of β-hCG.


Question: Vaccination against the causal pathogen of this patient's current disease is most likely to also prevent which of the following conditions?

Context: An 18-month-old boy is brought to the emergency department by his babysitter because of lethargy and fever for 3 hours.

Context: His temperature is 39.1°C (102.3°F).

Context: A pathogen is isolated from the patient's cerebrospinal fluid that does not grow on regular blood agar plate but produces colonies when cocultured with Staphylococcus aureus.

Choices:
A. Bacterial rhinosinusitis
B. Epiglottitis
C. Chancroid
D. Impetigo

Answer: Epiglottitis

1. An 18-month-old boy is brought to the emergency department by his babysitter.

2. The boy has been lethargic and has had a fever for 3 hours.

3. The boy had a middle ear infection a few days ago.

4. The parents cannot be reached for further information.

5. The boy's temperature is 39.1°C (102.3°F).

6. Physical examination shows nuchal rigidity.

7. A pathogen is isolated from the patient's cerebrospinal fluid.

8. The pathogen does not grow on regular blood agar plate.

9. The pathogen produces colonies when cocultured with Staphylococcus aureus.

1. He has not fully recovered from a middle ear infection that started a few days ago.

2. The parents cannot be reached for further information.

4. Physical examination shows nuchal rigidity.

5. A pathogen is isolated from the patient's cerebrospinal fluid.

6. The pathogen does not grow on regular blood agar plate.

7. The pathogen produces colonies when cocultured with Staphylococcus aureus.


Question: The serum concentration of which of the following substances is most likely to also be increased in this patient?

Context: He is unable to walk without support and speaks in unclear 2-word phrases.

Context: Examination shows multiple bruises on the forehead and several healing wounds over the fingers.

Choices:
A. Phenylalanine
B. Deoxyadenosine trisphosphate
C. Phosphoribosyl pyrophosphate
D. Cytosine monophosphate

Answer: Phosphoribosyl pyrophosphate

1. A 20-month-old boy is brought to the physician for the evaluation of intellectual and behavioral abnormalities and abnormal movements of his extremities.

2. His mother reports that he often hits his head and limbs against furniture.

3. He is unable to walk without support.

5. Examination shows multiple bruises on the forehead.

6. Examination shows several healing wounds over the fingers.

7. There is increased muscle tone in all extremities.

8. Laboratory studies show an increased serum uric acid concentration.

1. His mother reports that he often hits his head and limbs against furniture.

2. He is unable to walk without support.

4. Examination shows multiple bruises on the forehead.

5. Examination shows several healing wounds over the fingers.

6. There is increased muscle tone in all extremities.

7. Laboratory studies show an increased serum uric acid concentration.


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

Context: A 24-year-old man presents to the office for a physical exam and drug screening requested by his parole officer.

Choices:
A. Substance use-related aggression
B. Conduct disorder
C. Antisocial personality disorder
D. Borderline personality disorder

Answer: Antisocial personality disorder

1. A 24-year-old man presents to the office for a physical exam and drug screening.

2. The drug screening was requested by his parole officer.

3. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.

4. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.

5. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting before 12.

7. His mother states there were no stressful changes or issues at home.

8. Today's urine toxicology screens are negative.

1. He has a history of multiple run-ins with the law, including theft, destruction of property, and assault and battery.

2. Patient confesses that he has always been the 'problem child' in his home and always got into trouble with authority figures.

3. Past medical records reveal testimonies from his mother describing episodes of physically aggressive behavior in school starting at before 12.

4. Although a single parent, his mother states there were no stressful changes or issues at home.

5. Today's urine toxicology screens are negative.


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

Context: A 47-year old woman is referred to a nephrologist due to hematuria over the last week and lower extremity edema.

Context: This causes her mild joint and muscle pain on most day and she manages her symptoms with ibuprofen and acetaminophen.

Context: Today, her heart rate is 90/min, the respiratory rate is 17/min, the blood pressure is 140/90 mm Hg, and the temperature is 37.1°C (98.8°F).

Context: Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts.

Context: Serum creatinine is 2.4 mg/dL and a 24 hour urine collection reveals 550mg of excreted protein.

Choices:
A. Methotrexate and folic acid
B. Intravenous immunoglobulin
C. Plasmapheresis
D. Cyclophosphamide and prednisolone

Answer: Cyclophosphamide and prednisolone

1. A 47-year old woman is referred to a nephrologist.

2. She has had hematuria over the last week.

4. She first noticed her feet and legs would swell in the mornings about 2 weeks ago.

5. Her past medical history is significant for systemic lupus erythematosus for the past 24 years.

6. This causes her mild joint and muscle pain on most days.

7. She manages her symptoms with ibuprofen and acetaminophen.

12. Urine analysis shows 6-10 dysmorphic RBCs per high powered field.

13. Urine analysis also shows occasional cellular casts.

15. A 24 hour urine collection reveals 550mg of excreted protein.

16. A kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis.

1. Patient noticed swelling in feet and legs 2 weeks ago

2. Past medical history includes systemic lupus erythematosus for 24 years

3. SLE causes mild joint and muscle pain, managed with ibuprofen and acetaminophen

4. Current vital signs: heart rate 90/min, respiratory rate 17/min, blood pressure 140/90 mm Hg, temperature 37.1°C (98.8°F)

5. Urine analysis shows 6-10 dysmorphic RBCs per high powered field and occasional cellular casts

7. 24-hour urine collection reveals 550mg of excreted protein

8. Kidney biopsy shows findings consistent with diffuse proliferative glomerulonephritis


Question: Which pathological change would likely be seen on microscopy?

Context: A 6-year-old girl presents to your clinic two weeks after receiving a routine immunization in preparation for a trip overseas.

Context: Periorbital edema is present on exam, and 24 hour urine collection shows excretion of 4.3 grams of protein/day.

Choices:
A. Linear IgG deposition on light microscopy
B. IgA-immune complexes in the mesangium on electron microscopy
C. Subepithelial deposits with “spike and dome” appearance on electron microscopy
D. Podocyte effacement on electron microscopy

Answer: Podocyte effacement on electron microscopy

1. A 6-year-old girl presents to a clinic.

2. She received a routine immunization two weeks prior.

3. The immunization was in preparation for a trip overseas.

4. Periorbital edema is present on exam.

6. The urine collection showed excretion of 4.3 grams of protein/day.

1. Periorbital edema is present on exam.

2. 24 hour urine collection shows excretion of 4.3 grams of protein/day.


Question: Which of the following sets of laboratory findings is most likely in this patient's serum? |  $$$ Calcium %%% Phosphorus %%% Parathyroid hormone %%% Calcitriol $$$

Context: A 9-year-old girl is brought to the physician by her father for evaluation of intermittent muscle cramps for the past year and short stature.

Context: She is at the 5th percentile for weight and 10th percentile for height.

Context: Physical examination shows nasal polyps and dry skin.

Context: An x-ray of the right wrist shows osteopenia with epiphyseal widening.

Choices:
D. Normal ↓ ↑ ↓

1. A 9-year-old girl is brought to the physician by her father.

2. She has had intermittent muscle cramps for the past year.

3. She has had recurrent upper respiratory tract infections since infancy.

4. She is at the 5th percentile for weight.

5. She is at the 10th percentile for height.

6. Physical examination shows nasal polyps.

8. An x-ray of the right wrist shows osteopenia.

9. An x-ray of the right wrist shows epiphyseal widening.

1. She has had recurrent upper respiratory tract infections since infancy.

2. She is at the 5th percentile for weight.

3. She is at the 10th percentile for height.

4. Physical examination shows nasal polyps.

6. An x-ray of the right wrist shows osteopenia.

7. An x-ray of the right wrist shows epiphyseal widening.