Question: This patient most likely presents with clinical features of which disease?

Context: A 24-year-old man presents to his primary care physician with heel pain that has been persistent for 3 weeks now.

Choices:
A. Ankylosing spondylitis
B. Reactive arthritis
C. Osteoma
D. Fibromyalgia

Answer: Ankylosing spondylitis

Orthopaedic Sports Medicine
General Rheumatology

1. A 24-year-old man presents to his primary care physician.

2. He has heel pain that has been persistent for 3 weeks.

3. He is bothered by the feeling of significant pressure and swelling in his ankle.

4. He is having difficulty walking due to pain in his hip.

5. Upon physical examination, there is evidence of swelling and warmth over his Achilles tendon.

6. Imaging of his sacroiliac joint reveals soft tissue involvement and narrowing of the joint spaces.

7. This patient also appears to have a low to moderate kyphosis of his spine.

8. He has no family history of any bone or rheumatological diseases.

1. He is bothered by the feeling of significant pressure and swelling in his ankle.

2. He is also having difficulty walking due to pain in his hip.

3. Upon physical examination, there is evidence of swelling and warmth over his Achilles tendon.

4. Imaging of his sacroiliac joint reveals soft tissue involvement and narrowing of the joint spaces.

5. This patient also appears to have a low to moderate kyphosis of his spine.

6. He has no family history of any bone or rheumatological diseases.


Question: Which of the following should also be added to this patient’s therapeutic regimen?

Context: A 51-year-old man comes to his physician with chronic sinusitis and rhinorrhea for which he uses mometasone nasal spray.

Context: He is seeking a refill on this prescription, noting that, although it has not fully relieved his nasal symptoms over the past 2 years, it has helped minimize the severity of those symptoms.

Context: On auscultation, there are faint crackles in the bilateral lung fields and an indentation at the nasal bridge.

Context: The patient also notes occasional hemoptysis and hematuria.

Context: He has no significant medical history and takes no other medications.

Context: The physician is suspicious for granulomatosis with polyangiitis and a nasal mucosal biopsy is obtained which confirms the diagnosis.

Choices:
A. Azithromycin
B. Ganciclovir
C. Doxycycline
D. Trimethoprim/sulfamethoxazole

Answer: Trimethoprim/sulfamethoxazole

2. Patient has chronic sinusitis and rhinorrhea.

4. Patient is seeking a refill on the prescription.

5. Prescription has not fully relieved nasal symptoms over the past 2 years, but has helped minimize severity.

6. On auscultation, faint crackles in bilateral lung fields and indentation at nasal bridge.

7. Patient notes occasional hemoptysis and hematuria.

8. Patient has no significant medical history.

10. Family history is significant for rheumatoid arthritis.

11. Physician is suspicious for granulomatosis with polyangiitis.

12. Nasal mucosal biopsy is obtained which confirms diagnosis.

13. Patient is started immediately on prednisone and cyclophosphamide.

1. The patient is seeking a refill on a prescription.

2. The prescription has not fully relieved his nasal symptoms over the past 2 years.

3. The prescription has helped minimize the severity of those symptoms.

4. Faint crackles are heard in the bilateral lung fields on auscultation.

5. There is an indentation at the nasal bridge.

6. The patient experiences occasional hemoptysis.

7. The patient experiences occasional hematuria.

8. The patient has no significant medical history.

9. The patient takes no other medications.

11. The physician is suspicious for granulomatosis with polyangiitis.

13. The nasal mucosal biopsy confirms the diagnosis of granulomatosis with polyangiitis.

14. The patient is started immediately on prednisone and cyclophosphamide.


Question: Laboratory testing shows the following: | Serum Glucose (fasting) 100 mg/dL |   Sodium 142 mEq/L |   Potassium 3.9 mEq/L |   Chloride 101 mEq/L | Serum Creatinine 0.8 mg/dL | Blood Urea Nitrogen 10 mg/dL | Cholesterol, total 250 mg/dL |   HDL-cholesterol 34 mg/dL |   LDL-cholesterol 210 mg/dL | Triglycerides 160 mg/dL | The patient is most likely started on a medication which acts by which of the following mechanism?

Choices:
A. Blockage of beta-adrenergic receptors
B. Blockage of the angiotensin receptors
C. Increase loss of bile acids in the feces
D. Inhibition of HMG-CoA reductase

Answer: Inhibition of HMG-CoA reductase

1. A 28-year-old man presents to a clinic for a health check-up.

2. He says that he feels great and has not seen a physician for approximately 10 years.

3. His 3 older brothers have recently developed cardiac problems.

4. His medical history is significant for an appendectomy 16 years ago.

6. He eats a low-salt, well-balanced diet.

7. He drinks alcohol socially on the weekend.

12. The physical examination is unremarkable.

1. He feels great and has not seen a physician for approximately 10 years.

2. He is concerned about his health because his 3 older brothers have recently developed cardiac problems.

3. His medical history is significant for an appendectomy 16 years ago.

4. He works out twice a week and eats a low-salt, well-balanced diet.

5. He drinks alcohol socially on the weekend, but does not use tobacco or drugs.

6. The pulse is 80/min, respirations are 14/min, and the blood pressure is 129/80 mm Hg.

7. The physical examination is unremarkable.


Question: Which of the following potential actions by this patient would be an example of sublimation?

Context: A 17-year-old boy presents for a psychotherapy session after finding out that his girlfriend has been carrying on another relationship with someone else.

Context: He expresses rage and complains of difficulty focusing on his upcoming high school comedy club routines and upcoming track meet.

Context: His therapist, while explaining the concept of defense mechanisms, describes some hypothetical examples related to the situation.

Choices:
A. Channeling his anger about the situation into training for his track meet
B. Instigating a physical fight with his girlfriend’s other partner
C. Making jokes about the situation and incorporating them into his comedy routine
D. Not thinking about the upsetting situation until after his track meet, then confronting and processing his feelings about it

Answer: Channeling his anger about the situation into training for his track meet

1. A 17-year-old boy presents for a psychotherapy session.

2. He found out that his girlfriend has been carrying on another relationship with someone else.

4. He complains of difficulty focusing on his upcoming high school comedy club routines.

5. He complains of difficulty focusing on his upcoming track meet.

6. His therapist explains the concept of defense mechanisms.

7. His therapist describes some hypothetical examples related to the situation.

2. He complains of difficulty focusing on his upcoming high school comedy club routines.

3. He complains of difficulty focusing on his upcoming track meet.

4. His therapist explains the concept of defense mechanisms.

5. The therapist describes some hypothetical examples related to the situation.


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

Context: A 39-year-old woman is brought to the emergency room by her fiancé for severe abdominal pain for the past 5 hours.

Context: Ibuprofen also did not help.

Context: She reports recurrent abdominal pain that would self-resolve in the past but states that “this one is way worse.” Her past medical history is significant for diabetes and an appendectomy 2 years ago.

Context: The patient endorses nausea and 1 episode of emesis, but denies fevers, chills, chest pain, shortness of breath, diarrhea, constipation, urinary symptoms, paresthesia, or weakness.

Context: She used to smoke marijuana in college and drinks about 2 beers a week.

Context: Her vitals are within normal limits.

Context: Laboratory values are shown below: |  | Hemoglobin: 12 g/dL | Hematocrit: 34% | Leukocyte count: 4,900/mm^3 with normal differential | Platelet count: 160,000/mm^3 |  | Serum: | Na+: 138 mEq/L | Cl-: 98 mEq/L | K+: 4.8 mEq/L | HCO3-: 25 mEq/L  | Glucose: 123 mg/dL | Ca2+:  6.9 mg/dL | AST: 387 U/L | ALT: 297 U/L | ALP: 168 U/L | Lipase: 650 U/L (Normal 0 – 160 U/L) |  | .

Choices:
A. Abdominal computed tomography without IV contrast
B. Abdominal magnetic resonance imaging
C. Abdominal ultrasound
D. Upright chest and abdominal radiograph

Answer: Abdominal ultrasound

2. She was brought to the emergency room by her fiancé.

3. She has been experiencing severe abdominal pain for the past 5 hours.

4. She was watching TV after dinner when she felt a sudden, sharp, 10/10 pain at the epigastric region that did not go away.

6. She has had recurrent abdominal pain in the past that would self-resolve.

7. She states that “this one is way worse.”

8. Her past medical history is significant for diabetes and an appendectomy 2 years ago.

9. She endorses nausea and 1 episode of emesis.

10. She denies fevers, chills, chest pain, shortness of breath, diarrhea, constipation, urinary symptoms, paresthesia, or weakness.

11. She used to smoke marijuana in college.

13. Physical examination demonstrates an overweight woman in acute distress with diffuse abdominal tenderness.

14. Her vitals are within normal limits.

17. Leukocyte count: 4,900/mm^3 with normal differential

28. Lipase: 650 U/L (Normal 0 – 160 U/L)

1. The patient felt sudden, sharp, 10/10 pain at the epigastric region after watching TV after dinner.

2. Ibuprofen did not help with the pain.

3. The patient has a history of recurrent abdominal pain that would self-resolve in the past.

4. The patient's past medical history includes diabetes and an appendectomy 2 years ago.

5. The patient endorses nausea and 1 episode of emesis.

6. The patient denies fevers, chills, chest pain, shortness of breath, diarrhea, constipation, urinary symptoms, paresthesia, or weakness.

7. The patient used to smoke marijuana in college and drinks about 2 beers a week.

8. A physical examination demonstrates an overweight woman in acute distress with diffuse abdominal tenderness.

9. Laboratory values show: Hemoglobin: 12 g/dL, Hematocrit: 34%, Leukocyte count: 4,900/mm^3 with normal differential, Platelet count: 160,000/mm^3, Serum: Na+: 138 mEq/L, Cl-: 98 mEq/L, K+: 4.8 mEq/L, HCO3-: 25 mEq/L, Glucose: 123 mg/dL, Ca2+: 6.9 mg/dL, AST: 387 U/L, ALT: 297 U/L, ALP: 168 U/L, Lipase: 650 U/L (Normal 0 – 160 U/L).


Question: Which of the following is most likely to confirm the diagnosis for this patient?

Context: A 50-year-old man is evaluated for a 2-year history of intermittent, nonproductive, chronic cough, as well as mild dyspnea with exertion.

Context: He has a 20-pack-year history of smoking and is a current smoker.

Context: His medical history is significant for hypertension and type 2 diabetes mellitus, which he has controlled with diet and exercise.

Context: He also takes lisinopril.

Context: On physical examination, blood pressure is 125/76 mm Hg, pulse rate is 78/min, respiratory rate is 15/min, oxygen saturation is 98% (breathing room air), and his BMI is 25 kg/m2.

Context: There is no jugular venous distention.

Context: Heart sounds are normal, and there is no murmur.

Context: No peripheral edema is noted.

Choices:
A. Chest CT scan
B. Measurement of protease inhibitor
C. Spirometry
D. Cardiac catheterization

Answer: Spirometry

2. Patient has a 2-year history of intermittent, nonproductive, chronic cough.

3. Patient has mild dyspnea with exertion.

4. Patient has a 20-pack-year history of smoking.

6. Patient has a medical history of hypertension.

7. Patient has a medical history of type 2 diabetes mellitus.

8. Patient has controlled diabetes mellitus with diet and exercise.

10. Patient's blood pressure is 125/76 mm Hg.

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

13. Patient's oxygen saturation is 98% (breathing room air).

15. Patient has no jugular venous distention.

18. Auscultation of the lungs reveals faint, bilateral wheezing.

20. The remainder of the examination is normal.

1. He has a 20-pack-year history of smoking

3. His medical history is significant for hypertension

4. His medical history is significant for type 2 diabetes mellitus

5. He has controlled his diabetes with diet and exercise

10. His oxygen saturation is 98% (breathing room air)

12. There is no jugular venous distention

15. Auscultation of the lungs reveals faint, bilateral wheezing

17. The remainder of the examination is normal


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

Context: A 51-year-old woman presents with bilateral hand tremors.

Context: She has had these tremors for several years, and her symptoms have gradually worsened over time.

Context: The tremors are restricted to her hands and are most prominent when she is holding a cup of tea or a pen.

Context: The tremors get worse when she is under stress or exhausted, and they are starting to disrupt her work routine.

Context: Her past medical history is significant for a recent hospitalization for an asthma exacerbation.

Context: Current medications include salmeterol, medium-dose fluticasone, and a daily multivitamin.

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

Choices:
A. Baclofen
B. Primidone
C. Propranolol
D. Sodium valproate

Answer: Primidone

3. Patient has had tremors for several years.

4. Symptoms have gradually worsened over time.

6. Tremors are most prominent when holding a cup of tea or a pen.

7. Tremors get worse when under stress or exhausted.

8. Tremors are starting to disrupt work routine.

9. Patient denies walking difficulties, speech problems, and weakness.

10. Patient has past medical history of recent hospitalization for asthma exacerbation.

11. Current medications include salmeterol, medium-dose fluticasone, and daily multivitamin.

15. Vital signs are within normal limits.

16. Hands have noticeable tremor when in use.

17. Hands remain still when resting in lap.

1. The patient has had tremors for several years.

2. Her symptoms have gradually worsened over time.

3. The tremors are restricted to her hands.

4. The tremors are most prominent when she is holding a cup of tea or a pen.

5. The tremors worsen when she is under stress or exhausted.

6. The tremors are starting to disrupt her work routine.

7. She denies walking difficulties, speech problems, and weakness.

8. Her past medical history includes a recent hospitalization for an asthma exacerbation.

9. Her current medications include salmeterol, medium-dose fluticasone, and a daily multivitamin.

10. The patient denies smoking but drinks alcohol socially.

12. Her vital signs are within normal limits.

13. On physical examination, her hands have a noticeable tremor when in use and remain still while resting in her lap.


Question: If she was found to have a traumatic rupture of the aorta, where along the path of the aorta is the most common site of injury?

Context: A 39-year-old female was involved in a head-on collision motor vehicle accident.

Choices:
A. Ascending aorta
B. Site of attachment of ligamentum arteriosum
C. Aortic isthmus
D. Descending aorta - Thoracic aorta

Answer: Aortic isthmus

Cardiothoracic Surgery
Cardiovascular Disease

Congenital Cardiac Surgery
General Internal Medicine
Thoracic and Cardiac Surgery
General Thoracic Surgery

2. Head-on collision motor vehicle accident.

3. Involvement in a motor vehicle accident

4. Type of motor vehicle accident: head-on collision


Question: Which of the following is the most likely explanation for the direction of flow of blood across this shunt?

Context: A previously healthy 2-month-old boy is brought to the physician because of a 10-day history of poor feeding.

Context: He was born at 38 weeks' gestation.

Context: An ECG shows left-axis deviation.

Choices:
A. Communication between the right and left atria
B. Right ventricular outflow tract obstruction
C. Increase in pulmonary vascular resistance
D. Decrease in pulmonary vascular resistance

Answer: Decrease in pulmonary vascular resistance

2. Patient has a 10-day history of poor feeding.

3. Patient used to feed for 20 minutes, but now needs 40 minutes.

4. Patient struggles to breathe and sweats while feeding.

5. Patient was born at 38 weeks' gestation.

6. Patient is at the 20th percentile for length.

7. Patient is at the 10th percentile for weight.

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

9. Pulse oximetry on room air shows an oxygen saturation of 98%.

10. Grade 3/6 holosystolic murmur is heard at the left lower sternal border.

12. X-ray of the chest shows an enlarged left atrium and ventricle and increased pulmonary vascular markings.

13. Doppler echocardiography confirms the presence of an intracardiac shunt.

1. He used to feed for 20 minutes but now needs 40 minutes.

2. He struggles to breathe and sweats while feeding.

4. He is at the 20th percentile for length and 10th percentile for weight.

5. His vital signs are within normal limits.

6. Pulse oximetry on room air shows an oxygen saturation of 98%.

7. A grade 3/6 holosystolic murmur is heard at the left lower sternal border.

9. An x-ray of the chest shows an enlarged left atrium and ventricle and increased pulmonary vascular markings.

10. Doppler echocardiography confirms the presence of an intracardiac shunt.


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

Context: A 14-year-old boy is brought to the physician for a follow-up examination.

Context: He has allergic rhinitis and his only medication is cetirizine.

Context: He is at the 60th percentile for height and above the 95th percentile for weight and BMI.

Context: The right breast is unremarkable.

Context: Axillary and pubic hair is present.

Choices:
A. Adverse drug reaction
B. Leydig cell tumor
C. Ductal ectasia
D. Physiological development

Answer: Physiological development

3. Patient's only medication is cetirizine.

4. Patient is at the 60th percentile for height.

5. Patient is above the 95th percentile for weight and BMI.

6. Vital signs are within the normal limits.

7. Examination shows a slightly tender, firm, 1-cm subareolar mass in the left breast.

8. There are no changes in the skin or nipple.

10. There is no palpable axillary lymphadenopathy.

12. Examination of the penis and testis shows no abnormalities.

13. Neurologic examination shows no focal findings.

3. He is at the 60th percentile for height.

4. He is above the 95th percentile for weight and BMI.

5. Vital signs are within the normal limits.

6. Examination shows a slightly tender, firm, 1-cm subareolar mass in the left breast.

7. There are no changes in the skin or nipple.

9. There is no palpable axillary lymphadenopathy.

11. Examination of the penis and testis shows no abnormalities.

12. Neurologic examination shows no focal findings.


Question: Which of the following should be started post-mastectomy to improve the patient’s prognosis?

Context: A 54-year-old woman presents to her primary care physician complaining of a lump in her right breast.

Context: She first noticed it 1 month ago.

Context: She claims that the lump is not painful or itchy, and she denies any abnormal nipple bleeding or discharge.

Context: She has a family history of breast cancer, including both her mother and older sister.

Context: A mammogram is performed, which identifies an irregular mass with a fibrotically stranded border.

Context: A biopsy is performed that is positive for invasive ductal carcinoma.

Context: The patient is started on radiation induction therapy and scheduled for a modified radical mastectomy.

Context: Following tumor gene testing, the patient is found to be positive or the HER-2/neu oncogene.

Choices:
A. Anastrozole
B. Corticosteroids
C. Leuprolide
D. Trastuzumab

Answer: Trastuzumab

1. A 54-year-old woman presents to her primary care physician.

2. She is complaining of a lump in her right breast.

4. Now she is worried that it may have grown.

5. She claims that the lump is not painful or itchy.

6. She denies any abnormal nipple bleeding or discharge.

7. She has a family history of breast cancer.

8. Her mother and older sister both have breast cancer.

9. Physical examination reveals a firm, immobile lump in the upper right breast.

11. The mammogram identifies an irregular mass with a fibrotically stranded border.

13. The biopsy is positive for invasive ductal carcinoma.

14. The patient is started on radiation induction therapy.

15. The patient is scheduled for a modified radical mastectomy.

16. Following tumor gene testing, the patient is found to be positive for the HER-2/neu oncogene.

1. She first noticed the lump 1 month ago.

2. She is worried that the lump may have grown.

4. She denies abnormal nipple bleeding or discharge.

5. She has a family history of breast cancer.

6. Her mother and older sister had breast cancer.

7. Physical examination reveals a firm, immobile lump in the upper right breast.

8. A mammogram identifies an irregular mass with a fibrotically stranded border.

9. A biopsy is positive for invasive ductal carcinoma.

10. The patient is started on radiation induction therapy.

11. The patient is scheduled for a modified radical mastectomy.

12. Tumor gene testing shows the patient is positive for the HER-2/neu oncogene.


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

Context: His temperature is 99.2°F (37.3°C), blood pressure is 177/108 mmHg, pulse is 100/min, respirations are 18/min, and oxygen saturation is 98% on room air.

Context: A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level; however, a high dose of dexamethasone when administered results in no attenuation of cortisol release.

Choices:
A. Adrenal adenoma
B. Decreased ACTH level
C. Enlargement of the facial bones
D. History of smoking

Answer: History of smoking

1. A 48-year-old man presents to his primary care physician concerned about his weight.

2. He states he has been gaining weight though does not feel he has changed his diet.

3. The patient also states he has felt fatigued lately and not himself.

4. He denies taking any medications or using any illicit substances at baseline.

9. Oxygen saturation is 98% on room air.

10. Physical exam is notable for an obese man with striae on his abdomen.

11. A 24-hour urine free cortisol is collected and demonstrates an elevated cortisol level.

12. A high dose of dexamethasone when administered results in no attenuation of cortisol release.

13. A CT scan of the abdomen is within normal limits.

2. The patient does not feel he has changed his diet.

3. The patient has been feeling fatigued lately.

4. The patient denies taking any medications or using any illicit substances at baseline.

5. The patient's temperature is 99.2°F (37.3°C).

6. The patient's blood pressure is 177/108 mmHg.

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

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


Question: What is the Kozak consensus sequence?

Context: Advances in molecular biology have identified important factors and sequences required for transcription and translation of mRNA as well as multiple diseases associated with mutations.

Context: The Kozak sequence is one such finding from this research.

Choices:
A. A sequence box that binds to NF-1
B. An untranslated region downstream of the the stop codon
C. An initiator of translation proximal to the start codon
D. A site to which the 50S ribosome binds

Answer: An initiator of translation proximal to the start codon

Molecular Genetic Pathology
Clinical Genetics and Genomics

1. Advances in molecular biology have identified important factors and sequences required for transcription and translation of mRNA.

2. Advances in molecular biology have identified multiple diseases associated with mutations.

3. The Kozak sequence is one finding from this research.

1. The Kozak sequence is a finding from research.


Question: Which of the following is the strongest predisposing factor for this patient's condition?

Context: A 3-week-old male infant is brought to the physician by his parents because they noticed that his head has been tilted to the left since birth.

Context: Physical examination shows the head turned toward the left side and the chin rotated toward the right.

Choices:
A. Fetal macrosomia
B. Cesarean delivery
C. Intrauterine exposure to haloperidol
D. Preterm birth

Answer: Fetal macrosomia

General Orthopaedic Surgery
Pediatric Neurology

1. A 3-week-old male infant is brought to the physician by his parents.

2. His parents noticed that his head has been tilted to the left since birth.

3. Physical examination shows the head turned toward the left side.

4. The chin is rotated toward the right.

5. He cries during an attempt to rotate the head to the right.

6. There is a firm, well-circumscribed mass on the left lower side of the neck.

1. Physical examination shows the head turned toward the left side.

2. Physical examination shows the chin rotated toward the right.

3. He cries during an attempt to rotate the head to the right.

4. There is a firm, well-circumscribed mass on the left lower side of the neck.


Question: What is the most likely cause for the underlying abnormalities?

Context: A 13-month-old boy was brought to the clinic due to failure-to-thrive and mental impairment.

Context: The parents are healthy, but they previously had a child who died at 14 months of age.

Choices:
A. Structural protein mutation
B. Genomic imprinting
C. Lysosomal enzyme mutation
D. Mitochondrial gene mutation

Answer: Lysosomal enzyme mutation

Medical Genetics and Genomics
Pediatrics

General Medical Genetics and Genomics
Metabolic Genetics
General Pediatrics
Clinical Genetics and Genomics

1. A 13-month-old boy was brought to the clinic.

2. The reason for the visit was failure-to-thrive and mental impairment.

3. Retinal findings are shown in the picture.

5. The parents previously had a child who died at 14 months of age.

1. Retinal findings are shown in the picture.

3. The parents previously had a child who died at 14 months of age.


Question: What is the most likely cause of this lab abnormality in this patient?

Context: A 24-year-old woman who is 16 weeks pregnant comes to your office requesting a referral for an abortion.

Context: Upon questioning she states that she is scared that her baby will be "deformed" because on routine screening she was found to have an elevated level of alpha-fetoprotein.

Choices:
A. Trisomy 13
B. Trisomy 18
C. Trisomy 21
D. Inaccurate gestational age

Answer: Inaccurate gestational age

1. A 24-year-old woman has come to the office.

3. She is requesting a referral for an abortion.

4. She is scared that her baby will be "deformed".

5. She had a routine screening which showed an elevated level of alpha-fetoprotein.

1. The patient is scared about her baby being "deformed."

3. The routine screening showed an elevated level of alpha-fetoprotein.


Question: Evaluation of this patient's urine before treatment is initiated is most likely to show which of the following?

Context: A previously healthy 45-year-old man is brought to the emergency department after being found by a search and rescue team in the mountains.

Context: He has been without food or water for 30 hours.

Context: His temperature is 37°C (98.6°F), pulse is 123/min, respirations are 20/min, and blood pressure is 90/55 mm Hg.

Context: Physical examination shows decreased skin turgor and dry mucous membranes.

Choices:
A. Low urine sodium and low urine osmolality
B. Low urine sodium with hyaline casts
C. High urine protein with fatty casts
D. Low urine osmolality with RBC casts

Answer: Low urine sodium with hyaline casts

1. A 45-year-old man was brought to the emergency department.

2. He was found by a search and rescue team in the mountains.

3. He had been without food or water for 30 hours.

8. Physical examination showed decreased skin turgor.

9. Physical examination showed dry mucous membranes.

1. He has been without food for 30 hours.

2. He has been without water for 30 hours.

7. Physical examination shows decreased skin turgor.

8. Physical examination shows dry mucous membranes.


Question: Which of the following helps the bacterium in this infection bind to immunoglobulin and prevent phagocytosis when invading its host?

Context: A 14-year-old Caucasian male presents with painful erythematous and honey-colored crusted lesions around his mouth.

Context: Further analysis reveals bacteria that are beta-hemolytic, coagulase positive, catalase positive, and appear golden on the blood agar plate.

Choices:
A. Protein A
B. Staphylokinase
C. Exfoliatin A
D. Neurotoxin

Answer: Protein A

1. Patient is a 14-year-old Caucasian male.

2. Patient has painful erythematous and honey-colored crusted lesions around his mouth.

3. Culture of the lesions reveals gram-positive cocci in clusters.

4. Further analysis reveals bacteria that are beta-hemolytic.

5. Further analysis reveals bacteria that are coagulase positive.

6. Further analysis reveals bacteria that are catalase positive.

7. Further analysis reveals bacteria that appear golden on the blood agar plate.

1. Culture of the lesions reveals gram-positive cocci in clusters.

2. Further analysis reveals bacteria that are beta-hemolytic.

3. Further analysis reveals bacteria that are coagulase positive.

4. Further analysis reveals bacteria that are catalase positive.

5. Further analysis reveals bacteria that appear golden on the blood agar plate.


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

Context: A 70-year-old man comes to the physician for the evaluation of abdominal pain over the past month.

Context: He has not seen a doctor in 15 years.

Context: He drinks 2–3 cans of beer per day.

Context: He appears pale.

Choices:
A. Smoking history
B. Poor dietary habits
C. History of alcohol use
D. Diabetes mellitus

Answer: Smoking history

2. Patient has abdominal pain for the past month.

3. Patient describes epigastric pain that radiates to the back.

4. Patient has lost 10 kg (22 lbs) in the past 6 months.

5. Patient has a history of untreated type 2 diabetes mellitus.

6. Patient has not seen a doctor in 15 years.

7. Patient is retired and spends most of his time at home watching TV.

8. Patient rarely cooks and mainly eats fast food.

9. Patient has smoked one pack of cigarettes daily for the past 50 years.

10. Patient drinks 2-3 cans of beer per day.

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

14. Patient's blood pressure is 150/90 mm Hg.

15. Physical examination shows jaundice of the conjunctivae and the skin.

16. Abdomen is soft, with no rebound or guarding.

17. Laboratory studies show a serum glucose concentration of 260 mg/dL.

18. Abdominal sonography shows enlargement of the gallbladder.

1. The patient describes epigastric pain that radiates to the back.

2. He also reports a 10-kg (22-lb) weight loss over the past 6 months.

3. He has a history of untreated type 2 diabetes mellitus.

4. He has not seen a doctor in 15 years.

5. He is retired and spends most of his time at home watching TV.

6. He rarely cooks and mainly eats fast food.

7. He has smoked one pack of cigarettes daily for the past 50 years.

10. His temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg.

11. Physical examination shows jaundice of the conjunctivae and the skin.

12. The abdomen is soft, with no rebound or guarding.

13. Laboratory studies show a serum glucose concentration of 260 mg/dL.

14. Abdominal sonography shows enlargement of the gallbladder.


Question: Of the following options, which is the most likely diagnosis?

Context: A 63-year-old African American man with a history of hypertension and dyslipidemia presents to the emergency department with facial swelling and difficulty breathing.

Context: His blood pressure is 110/74 mm Hg, heart rate is 94/min, and respiratory rate is 20/min.

Choices:
A. Erysipelas
B. Facial lymphedema
C. Drug-induced angioedema
D. Contact dermatitis

Answer: Drug-induced angioedema

1. A 63-year-old African American man presented to the emergency department.

2. He has a history of hypertension and dyslipidemia.

3. Symptoms began suddenly that morning and continued to worsen.

4. He started taking lisinopril several weeks ago.

8. Physical examination is notable for swelling of his lips and inspiratory stridor.

9. Clinical lab results suggest a normal C1 esterase inhibitor level.

1. Symptoms began suddenly that morning.

3. He started taking lisinopril several weeks ago.

7. Physical examination is notable for swelling of his lips.

8. Physical examination is notable for inspiratory stridor.


Question: Which of the following is the greatest predisposing factor for this patient's condition?"

Context: A 21-year-old female college student comes to the physician because of a two-week history of vaginal itching and burning.

Context: She also noticed white vaginal discharge despite cleaning her genital area daily using a ""soap-free, natural"" vaginal douche.

Context: She has type 1 diabetes mellitus.

Context: Her vaginal pH is 4.4 and the microscopic image of a KOH preparation shows multiple pseudohyphae.

Choices:
A. Frequent vaginal douching
B. Unprotected sexual intercourse
C. Intrauterine device
D. Diabetes mellitus

Answer: Diabetes mellitus

1. Patient is a 21-year-old female college student.

2. Patient has a two-week history of vaginal itching and burning.

3. Patient has noticed white vaginal discharge despite cleaning her genital area daily using a "soap-free, natural" vaginal douche.

4. Patient is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.

5. Patient has type 1 diabetes mellitus.

6. Patient swims for the college swimming team.

7. Patient had an intrauterine device implanted 3 months ago and does not use barrier protection.

8. Patient smokes one pack of cigarettes per day and does not drink alcohol.

9. Speculum examination shows an erythematous vagina covered in copious white discharge.

11. Microscopic image of a KOH preparation shows multiple pseudohyphae.

1. The patient noticed white vaginal discharge despite cleaning her genital area daily using a "soap-free, natural" vaginal douche.

2. She is worried that she might have contracted a sexually transmitted disease after meeting her new boyfriend around one month ago.

4. The patient swims for the college swimming team.

5. She had an intrauterine device implanted 3 months ago and does not use barrier protection.

6. She smokes one pack of cigarettes per day and does not drink alcohol.

7. Speculum examination shows an erythematous vagina covered in copious white discharge.

9. The microscopic image of a KOH preparation shows multiple pseudohyphae.


Question: Which of the following likely contributes to her orthopedic problems?

Context: She suffers from regular joint pain in her fingers, and hip X-rays reveal low bone mineral density.

Context: She has a history of diabetes mellitus and was diagnosed 2 years ago with end-stage renal disease.

Choices:
A. Decreased serum aldosterone
B. Increased serum parathyroid hormone
C. Increased serum glucose
D. Chronic hypertension

Answer: Increased serum parathyroid hormone

1. A 72-year-old female recently fractured her hip in a fall.

2. She suffers from regular joint pain in her fingers.

3. Hip X-rays reveal low bone mineral density.

4. She has a history of diabetes mellitus.

5. She was diagnosed 2 years ago with end-stage renal disease.

6. Serum phosphate levels are markedly elevated.

1. She suffers from regular joint pain in her fingers.

2. Hip X-rays reveal low bone mineral density.

3. She has a history of diabetes mellitus.

4. She was diagnosed 2 years ago with end-stage renal disease.

5. Serum phosphate levels are markedly elevated.


Question: Which of the following chromosomes contain genes that may be mutated in this patient's disease?

Context: He says that he has no health concerns; however, his wife is concerned that he has become increasingly forgetful.

Context: For example, he has become forgetful during his daily activities and recently has been getting lost during errands like shopping.

Context: She says that these symptoms have been occurring for about a year.

Context: She says that she became alarmed when he started forgetting the names of their children.

Context: Finally, over the last month he has become more irritable, which has led to several confrontations at work.

Choices:
A. 1
B. 4
C. 18
D. 20

1. A 52-year-old man presents to his primary care physician for his annual check-up.

2. He says that he has no health concerns.

3. His wife is concerned that he has become increasingly forgetful.

4. He has become forgetful during his daily activities.

5. He has been getting lost during errands like shopping.

6. His wife says that these symptoms have been occurring for about a year.

7. He has started forgetting the names of their children.

8. Over the last month he has become more irritable.

9. This has led to several confrontations at work.

10. Based on the age of onset for his disease, the patient is referred for genetic testing.

1. The patient says he has no health concerns.

2. The patient's wife is concerned about his increasing forgetfulness.

3. The patient has been forgetful during daily activities.

4. The patient has been getting lost during errands like shopping.

5. The symptoms have been occurring for about a year.

6. The wife became alarmed when the patient started forgetting the names of their children.

7. Over the last month, the patient has become more irritable.

8. The patient has had several confrontations at work due to irritability.

9. The patient is referred for genetic testing based on the age of onset for his disease.


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

Context: A 23-year-old woman, gravida 2, para 1, at 13 weeks gestation, comes to the physician because of a 2-day history of burning pain during urination.

Context: Urine dipstick shows leukocyte esterase, urinalysis shows 10 WBCs/hpf, and Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.

Choices:
A. Oral levofloxacin
B. Intramuscular ceftriaxone
C. Oral erythromycin
D.
Intramuscular ceftriaxone and oral azithromycin
"

Answer:
Intramuscular ceftriaxone and oral azithromycin
"

4. Patient has a 2-day history of burning pain during urination.

5. Patient has been sexually active with different male partners during the pregnancy.

7. Patient has not had any fever, chills, or pelvic pain.

8. Physical examination shows thick, purulent discharge from the urethra.

9. Urine dipstick shows leukocyte esterase.

11. Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.

12. Pelvic ultrasound shows a viable intrauterine pregnancy.

1. She has been sexually active with different male partners during the pregnancy and did not use condoms.

2. She has not had any fever, chills, or pelvic pain.

3. Physical examination shows thick, purulent discharge from the urethra.

4. Urine dipstick shows leukocyte esterase.

6. Gram stain of the urethral swab shows polymorphonuclear leukocytes with intracellular gram-negative diplococci.

7. Pelvic ultrasound shows a viable intrauterine pregnancy.


Question: What is the most likely diagnosis?

Context: A 20-year-old college student is brought to his primary care physician by his parents over the New Years holiday because they are concerned about his behavior since right after high school graduation in May the spring before.

Context: Prior to this year, he was generally an outgoing and social young man, who now reportedly has been spending the majority of his time alone in his dorm room and room at home, where his mother and father have overheard him talking to other people when he has no guests.

Context: On exam, his appears to be otherwise healthy and his urine toxicology screen is negative.

Choices:
A. Schizoaffective disorder
B. Major depression
C. Schizophrenia
D. Schizophreniform disorder

Answer: Schizophrenia

Child and Adolescent Psychiatry
Schizophrenia

1. A 20-year-old college student is brought to his primary care physician by his parents.

2. The visit is over the New Years holiday.

3. The parents are concerned about his behavior since right after high school graduation in May the spring before.

4. Prior to this year, he was generally an outgoing and social young man.

5. He has been spending the majority of his time alone in his dorm room and room at home.

6. His mother and father have overheard him talking to other people when he has no guests.

7. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove.

8. The oak grove will soon takeover the student union building.

9. The voice encourages him to set the trees on fire for all to see.

10. On exam, his appears to be otherwise healthy.

11. His urine toxicology screen is negative.

1. Prior to this year, he was generally an outgoing and social young man.

2. He has reportedly been spending the majority of his time alone in his dorm room and room at home.

3. His mother and father have overheard him talking to other people when he has no guests.

4. When asked if anything was bothering him at school, he reports that at night the voice of the school's mascot encourages him to save the school from the large oak grove that will soon takeover the student union building by setting the trees on fire for all to see.

5. On exam, he appears to be otherwise healthy.

6. His urine toxicology screen is negative.


Question: This patient is at greatest risk for which of the following complications?

Choices:
A. Hyperesthesia of the left ear lobe
B. Impaired taste of the posterior 1/3 of the tongue
C. Flushing of the right cheek while eating
D. Inability to wrinkle the left side of the forehead

Answer: Inability to wrinkle the left side of the forehead

General Dermatology
General Otolaryngology

1. A 58-year-old man comes to the physician for evaluation of an increasing left-sided cheek swelling and recurrent oral ulcers for 1 year.

2. He has smoked a pack of cigarettes daily for 25 years.

3. Examination shows a mild, nontender swelling above the angle of the left jaw.

4. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.

5. A left-sided total parotidectomy is performed.

1. He has smoked a pack of cigarettes daily for 25 years.

2. Examination shows a mild, nontender swelling above the angle of the left jaw.

3. An ultrasound-guided biopsy of the mass confirms the diagnosis of parotid adenoid cystic carcinoma.

4. A left-sided total parotidectomy is performed.


Question: Which of the following responses by the physician is the most appropriate?

Context: A 34-year-old man comes to the physician for a routine health maintenance examination required for his occupation as a school bus driver.

Context: He feels well and healthy.

Context: Upon questioning, he reports that he has smoked 2 joints of marijuana every night after work for the past year for recreational purposes.

Context: He typically smokes 5 joints or more on weekends.

Choices:
A. """Let me know when you are ready to stop smoking marijuana. We can talk about specific strategies to help you quit at that time."""
B. """Have you ever experienced a situation in which you wished you smoked less marijuana?"""
C. """We have a great program to help patients with substance use disorder issues. Let me give you more information about specific details."""
D. """You should stop smoking marijuana because it is not good for your health."""

Answer: """Have you ever experienced a situation in which you wished you smoked less marijuana?"""

1. A 34-year-old man comes to the physician for a routine health maintenance examination.

2. The man's occupation is a school bus driver.

4. The man has smoked 2 joints of marijuana every night after work for the past year.

5. The man smokes marijuana for recreational purposes.

6. The man typically smokes 5 joints or more on weekends.

2. The patient has smoked 2 joints of marijuana every night after work for the past year for recreational purposes.

3. The patient typically smokes 5 joints or more on weekends.


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

Context: A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father who is concerned about the child developing a body odor.

Context: Her temperature is 99°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 85/min, and respirations are 18/min.

Choices:
A. Aldosterone
B. Cortisol
C. 11-deoxycorticosterone
D. Leutenizing hormone

Answer: 11-deoxycorticosterone

1. A 6-year-old girl of Moroccan descent is brought to the pediatrician by her father.

2. The father is concerned about the child developing a body odor.

3. He reports that she has started to smell “like a teenage boy” especially after physical activity.

4. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age.

9. On exam, she has hair in her axillary and pubic regions.

10. Genital examination demonstrates clitoral enlargement and labioscrotal fusion.

1. The patient reports that she has started to smell "like a teenage boy" especially after physical activity.

2. The child has had limited medical follow-up since being born in Morocco and immigrating to the United States at 3 years of age.

7. On exam, she has hair in her axillary and pubic regions.

8. Genital examination demonstrates clitoral enlargement and labioscrotal fusion.


Question: While getting up to leave, the patient asks “why is it that I always get these symptoms but my husband is fine?” What is the most appropriate answer to this patient’s question?

Context: She is a newlywed and reports 3 similar episodes within the past 4 months.

Context: She is currently sexually active with her husband and has an IUD.

Choices:
A. Her partner is an asymptomatic carrier
B. Inadequate treatment of her prior episodes
C. The female urethra is shorter
D. The patient is experiencing recurrence of her past chlamydial infection

Answer: The female urethra is shorter

1. A 25-year-old woman presents to the clinic for burning with urination.

2. She reports 3 similar episodes within the past 4 months.

3. She claims that since yesterday she has noticed a burning sensation whenever she urinates, an increase in urinary frequency, and some clear vaginal discharge.

4. She denies fever, chills, back pain, or chest pain.

5. Her past medical history is significant for chlamydia that was adequately treated 3 years ago.

7. She is currently sexually active with her husband.

9. She is subsequently prescribed a course of nitrofurantoin for her symptoms.

3. Since yesterday, she has noticed a burning sensation whenever she urinates.

4. She has noticed an increase in urinary frequency since yesterday.

5. She has noticed some clear vaginal discharge since yesterday.

10. Her past medical history is significant for chlamydia.

11. The chlamydia was adequately treated 3 years ago.

12. She is currently sexually active with her husband.

14. She is subsequently prescribed a course of nitrofurantoin for her symptoms.


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

Context: A 17-year-old boy comes to the physician 1 week after noticing a lesion on his penis.

Context: He takes no medications.

Context: A photograph of the lesion is shown.

Choices:
A. Mycoplasma genitalium
B. Human papillomavirus
C. Treponema pallidum
D. Herpes simplex virus type 2

Answer: Treponema pallidum

1. A 17-year-old boy comes to the physician.

2. He noticed a lesion on his penis 1 week ago.

3. There is no history of itching or pain associated with the lesion.

4. He is sexually active with two female partners.

6. He returned from a trip to the Caribbean with some of his football teammates 5 weeks ago.

8. He has recently started an intense exercise program.

9. His vital signs are within normal limits.

10. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.

11. A photograph of the lesion is shown.

1. No history of itching or pain associated with the lesion.

2. He is sexually active with two female partners and uses condoms inconsistently.

3. Five weeks ago, he returned from a trip to the Caribbean with some of his football teammates.

5. He has recently started an intense exercise program.

6. His vital signs are within normal limits.

7. Physical examination shows multiple enlarged, nontender lymph nodes in the inguinal area bilaterally.


Question: Which of the following constitutes the first-line therapy in this patient?

Context: His temperature is 38.5°C (101.5°F).

Choices:
A. Erythromycin
B. Ceftazidime
C. Penicillin
D. Sulfisoxazole

Answer: Sulfisoxazole

1. A 36-year-old man presents to a physician for a post-transplant medical evaluation.

2. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.

3. He complains of fever, cough, and anorexia for the last 6-7 days.

4. His cough is productive of thick sputum.

6. The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.

7. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.

8. A sputum analysis reveals branched, irregular, gram-positive filamentous rods.

1. He has been taking prednisone and azathioprine for the last 6 months after receiving a cadaveric renal transplant.

2. He complains of fever, cough, and anorexia for the last 6-7 days.

3. His cough is productive of thick sputum.

5. The physical examination is significant for diminished breath sounds over the left lower lung with dullness on percussion and increased vocal resonance.

6. A left lower lobe nodule, 5 cm (2 in) in diameter with eccentric central cavitation, is visible on the chest X-ray.

7. A sputum analysis reveals branched, irregular, gram-positive filamentous rods.


Question: Which of the following is a reasonable first step in the management of this patient's condition?

Context: A 54-year-old woman presents to her gynecologist complaining of incontinence.

Context: She reports leakage of a small amount of urine when she coughs or laughs as well as occasionally when she is exercising.

Context: She denies any pain with urination.

Context: She underwent menopause 2 years ago and noted that this problem has increased in frequency since that time.

Context: Her history is significant only for three uncomplicated pregnancies with vaginal births.

Context: Urinalysis, post-void residual, and cystometrogram are conducted and all show normal results.

Context: The patient's vital signs are as follows: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%.

Context: Physical examination is significant for pelvic organ prolapse on pelvic exam.

Choices:
A. Kegel exercises
B. Bethanechol
C. Urethropexy
D. Tension-free vaginal tape

Answer: Kegel exercises

Female Pelvic Medicine and Reconstructive Surgery

2. Patient is complaining of incontinence.

3. Patient reports leakage of small amount of urine when coughing, laughing, and exercising.

4. Patient denies any pain with urination.

5. Patient underwent menopause 2 years ago.

6. Problem has increased in frequency since menopause.

7. Patient has had three uncomplicated pregnancies with vaginal births.

8. Urinalysis, post-void residual, and cystometrogram show normal results.

14. Pelvic organ prolapse is present on pelvic exam.

1. The patient reports leakage of a small amount of urine when she coughs or laughs.

2. The patient reports leakage of urine occasionally when she is exercising.

3. The patient denies any pain with urination.

4. The patient underwent menopause 2 years ago.

5. The patient noted that the urinary leakage problem has increased in frequency since menopause.

6. The patient has a history of three uncomplicated pregnancies with vaginal births.

8. Post-void residual test shows normal results.

10. The patient's vital signs are: T 37.5 C, HR 80, BP 128/67, RR 12, and SpO2 99%.

11. Physical examination shows pelvic organ prolapse on pelvic exam.


Question: What is this metric also known as?

Context: Researchers from a public health institute located in the United States conducted a multicenter cohort study on a large number of elderly individuals in order to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation.

Context: After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine compared to 20% of diseased study participants in the control group that did not receive the vaccine.

Context: If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development.

Choices:
A. Event rate
B. Risk difference
C. Relative risk reduction
D. Absolute risk reduction

Answer: Relative risk reduction

Public Health and General Preventive Medicine

1. Researchers from a public health institute located in the United States conducted a multicenter cohort study.

2. The study was conducted on a large number of elderly individuals.

3. The purpose of the study was to evaluate the protective effect of the new vaccine for herpes zoster (commonly known as shingles) reactivation.

4. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine.

5. 20% of diseased study participants in the control group that did not receive the vaccine developed shingles.

6. If the new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation (e.g., 40% and 10% risk), the calculated protective proportion of 25% would be maintained.

7. This would be true regardless of the different baseline risk for shingles development.

1. After a long follow-up period, the data shows that shingles developed in 15% of study participants who received the new vaccine.

2. Shingles developed in 20% of diseased study participants in the control group that did not receive the vaccine.

3. The new vaccine showed identical efficacy in groups with higher and lower risks of herpes zoster reactivation.

5. The calculated protective proportion of 25% would be maintained, regardless of the different baseline risk for shingles development.


Question: Which of the following has most likely been the long-term mechanism of his disease development?

Context: PFTs are performed describing a restrictive lung process.

Choices:
A. Eosinophilic reaction
B. Phagocytosis of silica
C. Tuberculosis
D. Defective mucociliary transport

Answer: Phagocytosis of silica

1. A 55-year-old gentleman has been working in a sand blasting factory for over 25 years.

2. He presents to his primary care physician with what he describes as increasing shortness of breath.

4. PFTs describe a restrictive lung process.

1. The patient presents to his primary care physician.

2. He describes increasing shortness of breath.

3. Pulmonary function tests (PFTs) are performed.

4. The PFTs describe a restrictive lung process.


Question: Which of the following pathogens is most likely responsible for this patient’s opportunistic infection?

Context: A 37-year-old man presents to the emergency department with acute loss of vision, slurred speech, and agitation.

Context: Past medical history is significant for HIV and hepatitis C, diagnosed 10 years ago for which he is non-compliant with medication.

Choices:
A. Herpes virus 8
B. Candida albicans
C. JC virus
D. Pneumocystis jirovecii

Answer: JC virus

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

2. Symptoms include acute loss of vision, slurred speech, and agitation.

3. Patient has a past medical history of HIV and hepatitis C.

4. HIV and hepatitis C were diagnosed 10 years ago.

5. Patient is non-compliant with medication.

7. MRI shows asymmetric, hypointense white matter lesions.

1. Past medical history includes HIV and hepatitis C.

2. HIV and hepatitis C were diagnosed 10 years ago.

3. The patient is non-compliant with medication for HIV and hepatitis C.

4. A T1 MRI of the brain shows asymmetric, hypointense white matter lesions.


Question: Which of the following infectious agents is the most likely cause of this patient's skin condition?

Context: A 4-year-old girl is brought to the physician for evaluation of a rash that her mother noticed 5 months ago.

Context: The rash is not painful or itchy but she notices that her daughter sometimes picks at the “spots.” The girl's 2-year-old brother has also started developing similar skin lesions over the past month.

Context: The patient has no history of serious illness and takes no medications.

Context: She is in the 75th percentile for height and 50th percentile for weight.

Choices:
A. Human herpesvirus 8
B. Human papillomavirus
C. Poxvirus
D. Varicella-zoster virus

Answer: Poxvirus

1. A 4-year-old girl is brought to the physician for evaluation of a rash.

2. The rash was noticed by the mother 5 months ago.

4. The girl sometimes picks at the “spots.”

5. The girl's 2-year-old brother has also started developing similar skin lesions over the past month.

6. The patient has no history of serious illness.

8. The patient is in the 75th percentile for height.

9. The patient is in the 50th percentile for weight.

10. A photograph of the patient's rash is shown.

2. The patient's daughter sometimes picks at the "spots."

3. The girl's 2-year-old brother has started developing similar skin lesions over the past month.

4. The patient has no history of serious illness.

6. The patient is in the 75th percentile for height.

7. The patient is in the 50th percentile for weight.

8. A photograph of the patient's rash is shown.


Question: This patient's symptoms are most likely due to taking an antibiotic that inhibits which of the following enzymes?

Context: He takes metformin and lisinopril.

Context: His temperature is 101°F (38.3°C).

Choices:
A. 30S ribosomal subunit
B. 50S ribosomal subunit
C. Dihydropteroate synthetase
D. DNA-dependent RNA polymerase

Answer: 50S ribosomal subunit

General Emergency Medicine
General Surgery

1. A 51-year-old police officer is brought to the emergency room after being shot in the abdomen.

2. His wound was packed and bandaged by emergency medical services before he was transported to the hospital.

3. His past medical history is notable for hypertension and diabetes.

5. He has a 20-pack-year smoking history and does not drink alcohol.

6. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.

7. On exam, he appears uncomfortable but is able to answer questions appropriately.

8. He has a 1 cm x 1 cm wound in the left upper quadrant.

9. There is an exit wound in the left lower back.

10. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.

11. No involvement of the colon or small intestine is noted intraoperatively.

12. He is placed on the appropriate antibiotic and pain control regimens.

13. Three days later, he experiences several episodes of non-bloody diarrhea.

15. Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon.

1. His wound was packed and bandaged by emergency medical services before he was transported to the hospital.

2. His past medical history is notable for hypertension and diabetes.

4. He has a 20-pack-year smoking history and does not drink alcohol.

5. His temperature is 98.6°F (37°C), blood pressure is 142/86 mmHg, pulse is 120/min, and respirations are 24/min.

6. On exam, he appears uncomfortable but is able to answer questions appropriately.

7. He has a 1 cm x 1 cm wound in the left upper quadrant.

8. There is an exit wound in the left lower back.

9. After undergoing the appropriate laboratory and imaging tests, he undergoes a diagnostic laparotomy.

10. No involvement of the colon or small intestine is noted intraoperatively.

11. He is placed on the appropriate antibiotic and pain control regimens.

12. Three days later, he experiences several episodes of non-bloody diarrhea.

14. Sigmoidoscopy reveals multiple pseudomembranous plaques in the sigmoid and descending colon.


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

Context: A 3-year-old girl is brought to the physician by her parents for the evaluation of vaginal discharge for one month.

Context: Vital signs are within normal limits.

Choices:
A. Vaginal irrigation with warm saline
B. Vacuum suction
C. Alert Child Protective Services
D. Administration of oral metronidazole

Answer: Vaginal irrigation with warm saline

Pediatric Infectious Diseases
Pediatric Gastroenterology
Pediatric Urology

1. A 3-year-old girl is brought to the physician by her parents.

2. The patient has had vaginal discharge for one month.

3. The discharge is foul-smelling and contains some blood.

4. The patient sometimes has pain with urination.

5. She has not had increased urinary frequency or abdominal pain.

6. Topical vaginal cream application did not improve the patient's symptoms.

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

8. She lives with her parents and attends a local daycare center.

9. Vital signs are within normal limits.

10. Examination of the vulva and vaginal entrance shows an intact hymen.

11. Examination of the vulva and vaginal entrance shows vaginal erythema with blood-tinged, foul-smelling discharge.

12. Examination of the vulva and vaginal entrance shows the tip of a white object.

13. The remainder of the examination shows no abnormalities.

1. The discharge is foul-smelling and contains some blood.

2. The patient sometimes has pain with urination.

3. She has not had increased urinary frequency or abdominal pain.

4. Topical vaginal cream application did not improve the patient's symptoms.

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

6. She lives with her parents and attends a local daycare center.

7. Vital signs are within normal limits.

8. Examination of the vulva and vaginal entrance shows an intact hymen, vaginal erythema with blood-tinged, foul-smelling discharge, and the tip of a white object.

9. The remainder of the examination shows no abnormalities.


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

Context: A 60-year-old man comes to the physician because of a 3-month history of a slowly enlarging painless ulcer on his lower lip.

Context: One year ago he had a painful rash near his upper lip that resolved completely with acyclovir therapy.

Choices:
A. Squamous cell carcinoma
B. Aphthous stomatitis
C. Psoriasis
D. Seborrheic keratosis

Answer: Squamous cell carcinoma

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

2. He has a 3-month history of a slowly enlarging painless ulcer on his lower lip.

3. One year ago he had a painful rash near his upper lip.

4. The rash resolved completely with acyclovir therapy.

5. He has a 10-year history of type 2 diabetes mellitus.

7. He has worked in construction for the past 33 years.

8. He has smoked one pack of cigarettes daily for 35 years.

9. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.

10. The erythematous ulcer bleeds upon palpation.

11. He has numerous moles of varying sizes all over his body.

12. There are no palpable cervical lymph nodes.

1. One year ago, he had a painful rash near his upper lip that resolved completely with acyclovir therapy.

2. He has a 10-year history of type 2 diabetes mellitus treated with metformin.

3. He has worked in construction for the past 33 years.

4. He has smoked one pack of cigarettes daily for 35 years.

5. Examination shows a 0.5 x 0.5 cm nontender ulcer with everted edges on the midline of his lower lip.

6. The erythematous ulcer bleeds upon palpation.

7. He has numerous moles of varying sizes all over his body.

8. There are no palpable cervical lymph nodes.


Question: Which of the following is the patient most at risk for developing?

Context: A 3-year-old girl is brought to the pediatrician by her father for fever and cough.

Context: The patient’s father states that she had a sore throat and runny nose 2 weeks ago.

Context: Then last night she developed a productive cough and a fever.

Context: The father is worried that this is pneumonia again, and reports that she has been hospitalized 5 times already with pneumonia.

Context: Her medical history is also significant for chronic diarrhea.

Context: The father reports that the patient has 2 older brothers who are both healthy.

Context: The patient’s temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.

Context: An antibody panel and flow cytometry are obtained in the setting of the patient’s recurrent infections.

Choices:
A. Ataxia
B. Atopic dermatitis
C. Blurry vision
D. Scant tonsils

Answer: Blurry vision

1. A 3-year-old girl is brought to the pediatrician by her father.

2. The patient had a sore throat and runny nose 2 weeks ago.

3. Last night she developed a productive cough and a fever.

4. The father is worried that this is pneumonia again.

5. The patient has been hospitalized 5 times already with pneumonia.

6. The patient has a medical history of chronic diarrhea.

7. The patient has 2 older brothers who are both healthy.

8. The patient's temperature is 102°F (38.9°C).

9. The patient's blood pressure is 102/60 mmHg.

11. The patient's respirations are 28/min with an oxygen saturation of 94% on room air.

12. On physical examination, decreased breath sounds are appreciated on the right.

13. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.

14. An antibody panel and flow cytometry are obtained in the setting of the patient's recurrent infections.

15. The results show a normal lymphocyte count.

16. The results show low levels of IgA, IgG, and IgE.

17. The results show elevated levels of IgM.

1. The patient had a sore throat and runny nose 2 weeks ago.

2. Last night, the patient developed a productive cough and a fever.

3. The patient has been hospitalized 5 times already with pneumonia.

4. The patient's medical history is significant for chronic diarrhea.

5. The patient has 2 older brothers who are both healthy.

6. The patient's temperature is 102°F (38.9°C), blood pressure is 102/60 mmHg, pulse is 110/min, and respirations are 28/min with an oxygen saturation of 94% on room air.

7. On physical examination, decreased breath sounds are appreciated on the right.

8. A chest radiography shows consolidation in the right upper lobe, consistent with pneumonia.

9. An antibody panel and flow cytometry are obtained in the setting of the patient's recurrent infections.

10. The results show a normal lymphocyte count with low levels of IgA, IgG, and IgE and elevated levels of IgM.


Question: Which type of patient would least likely have these same diagnostic findings?

Context: A 72-year-old man presents with urinary frequency resulting in frequent awakening to urinate at night.

Context: He is a retired elite runner and does not have a history of any chronic medical conditions.

Context: The patient is not in distress.

Context: There is no CVA tenderness.

Context: Furthermore, post-void residual volume is > 100 mL.

Choices:
A. A 55-year-old Egyptian man with painless hematuria, 18.1 kg (40 lb) incidental weight loss and confirmed Schistosoma hematobium infection
B. A 27-year-old woman with waxing and waning internuclear ophthalmoplegia, scanning speech, and optic neuritis
C. An ICU patient with a kinked Foley catheter
D. A 35-year-old woman with severe colicky pain radiating to the left flank

Answer: A 35-year-old woman with severe colicky pain radiating to the left flank

3. Patient has urinary frequency resulting in frequent awakening to urinate at night.

4. Patient does not have a history of any chronic medical conditions.

5. Patient denies weight loss, bone pain, or pain with urination.

11. Digital rectal exam reveals a smooth, non-tender, uniformly enlarged prostate.

13. Bilateral hydronephrosis on ultrasound.

19. Post-void residual volume is > 100 mL.

1. The patient is a retired elite runner.

2. The patient does not have a history of any chronic medical conditions.

3. The patient denies weight loss, bone pain, or pain with urination.

5. Vitals show: temperature 36.8°C (98.2°F), heart rate 98/min, respiratory rate 15/min, and blood pressure 100/75 mm Hg.

6. Physical exam is significant for a smooth, non-tender, uniformly enlarged prostate on digital rectal exam.

8. CBC, CMP, urinalysis, and abdominal ultrasound are ordered.

9. Significant findings include: bilateral hydronephrosis on ultrasound, BUN/creatinine > 20:1, specific gravity > 1,020, FENa < 1%, urine Na < 20, and urine osmolality > 450 mOsm/kg.

10. Post-void residual volume is > 100 mL.


Question: Which of the following is the most likely etiology of his bruises?

Context: An 82-year-old man with Alzheimer disease is brought to the physician by his daughter because of extensive bruising on his arms.

Context: His hemoglobin concentration is 11.7 g/dL, mean corpuscular volume is 78 μm3, and platelet count is 180,000/mm3.

Choices:
A. Platelet aggregation inhibition
B. Intravascular coagulation with fibrinolysis
C. Nonaccidental trauma
D. Vitamin K deficiency

Answer: Nonaccidental trauma

1. An 82-year-old man has Alzheimer disease.

2. He was brought to the physician by his daughter.

3. He has extensive bruising on his arms.

4. He lives in an assisted living facility.

5. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.

6. His hemoglobin concentration is 11.7 g/dL.

7. His mean corpuscular volume is 78 μm3.

9. Coagulation studies are within normal limits.

1. He lives in an assisted living facility.

2. Physical examination shows large ecchymoses across both forearms and upper arms in varied stages of healing.

3. His hemoglobin concentration is 11.7 g/dL.

6. Coagulation studies are within normal limits.


Question: On bimanual examination, the uterus is normal size, non-tender, and mobile adnexa is non-palpable. | The pap smear result is as follows: | The pap smear result is as follows: | Specimen adequacy: satisfactory for evaluation | Interpretation: negative for intraepithelial lesion or malignancy | Notes: absent transformation zone component | How should we proceed with the management of this patient?

Context: She is nulliparous, does not report any gynecologic or systemic diseases, and has no complaints.

Context: She is sexually active with one partner and uses oral contraceptive pills.

Context: Her vital signs are as follows: blood pressure 125/70 mm Hg, heart rate 81/min, respiratory rate 12/min, and temperature 36.6℃ (97.9℉).

Context: The breast examination is normal.

Context: No pathology is noted in the external genitalia and a speculum examination reveals a normal cervix with a closed external os and no discharge.

Choices:
A. Repeat Pap test in 3 years as a usual screening schedule suggests
B. Repeat Pap test within 2 weeks and ensure proper sampling from the transformation zone
C. Perform a screening test for high-risk human papillomavirus (HPV)
D. Perform a HPV testing and Pap smear in one year

Answer: Repeat Pap test in 3 years as a usual screening schedule suggests

1. A 23-year-old woman presents to her gynecologist for a routine visit.

3. She does not report any gynecologic or systemic diseases.

5. She is sexually active with one partner.

11. The physical examination is within normal limits.

13. No pathology is noted in the external genitalia.

14. A speculum examination reveals a normal cervix with a closed external os and no discharge.

15. A specimen is obtained from the cervical portion for a Pap smear.

2. She does not report any gynecologic or systemic diseases.

4. She is sexually active with one partner.

10. The physical examination is within normal limits.

12. No pathology is noted in the external genitalia.

13. A speculum examination reveals a normal cervix with a closed external os and no discharge.

14. A specimen is obtained from the cervical portion for a Pap smear.


Question: Which of the following best describe the primary disorder in this patient?

Choices:
A. Obstruction of the lumen of the appendix
B. Inflammation of the renal parenchyma, calyces and pelvis
C. Herniation of mucosa and submucosa through the muscular layer of the colon
D. Inflammation of the upper genital tract

Answer: Herniation of mucosa and submucosa through the muscular layer of the colon

1. A 57-year-old woman presents to the emergency department with acute pain in the left lower abdomen associated with nausea and vomiting for the past 24 hours.

2. Prior to this episode, the patient did not have any significant gastrointestinal (GI) problems except for occasional constipation and indigestion after heavy meals.

3. She has had hypertension and hypercholesterolemia for the past 7 years.

4. Her family history is negative for GI disorders.

5. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.

6. On physical examination, there is tenderness in the left lower abdominal quadrant.

7. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat.

1. The patient had occasional constipation and indigestion after heavy meals prior to the current episode.

2. The patient has had hypertension and hypercholesterolemia for the past 7 years.

3. The patient's family history is negative for GI disorders.

4. Vital signs include a temperature of 38.0°C (100.4°F), blood pressure of 120/80 mm Hg, and pulse of 85/min.

5. On physical examination, there is tenderness in the left lower abdominal quadrant.

6. Abdominal CT scan shows thickening of the bowel wall and streaky mesenteric fat.


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

Context: A 35-year-old woman comes to the emergency department because of a 3-day history of pain in the left cheek.

Context: The pain occurs every few hours, lasts 30–60 seconds, and is aggravated by chewing and brushing.

Choices:
A. Cluster headache
B. Trigeminal neuralgia
C. Postherpetic neuralgia
D. Temporal arteritis

Answer: Trigeminal neuralgia

General Neurology
Pain Medicine
Headache Medicine

1. A 35-year-old woman comes to the emergency department.

2. She has a 3-day history of pain in the left cheek.

5. The pain is aggravated by chewing and brushing.

6. She has a history of pain with a vesicular rash in the right axillary area one year ago.

7. She had an upper respiratory infection 2 weeks ago.

8. Physical examination shows no abnormalities.

3. The pain is aggravated by chewing and brushing.

4. She has a history of pain with a vesicular rash in the right axillary area one year ago.

5. She had an upper respiratory infection 2 weeks ago.

6. Physical examination shows no abnormalities.


Question: Which of the following chromosomes is most likely mutated in association with this patient's condition?

Context: The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm and he appears to be in no acute distress.

Context: Upon obtaining a history you learn that this patient also complains that at times the "room feels like it's spinning." You also notice throughout the interview that you have to speak loudly as the patient has difficulty hearing.

Context: The patient is then lost to follow up for his current condition.

Context: The patient returns several years later with worsening symptoms and as part of this patient's workup a MRI is obtained (Image A).

Choices:
A. Chromosome 13
B. Chromosome 17
C. Chromosome 22
D. The X chromosome

Answer: Chromosome 22

1. A 45 year old male presents to clinic complaining of a ringing in his ears.

3. Patient appears to be in no acute distress.

4. Patient also complains that at times the "room feels like it's spinning."

6. Patient is then lost to follow up for his current condition.

7. Patient returns several years later with worsening symptoms.

1. The patient's vitals are: BP 120/65, RR 16, 100% on room air, HR 78 bpm.

2. The patient appears to be in no acute distress.

3. The patient complains of feeling like the "room feels like it's spinning."

5. The patient is lost to follow up for his current condition.

6. The patient returns several years later with worsening symptoms.

7. A MRI is obtained as part of the patient's workup (Image A).


Question: What is the most likely diagnosis?

Context: A 35-year-old is brought into the emergency room after a bicycle vs motored vehicle accident.

Context: He was unconscious after hitting the side of his head on the road, but recovered consciousness after a few minutes.

Context: He started to ride his bicycle again, but then developed a severe headache with nausea and vomiting, at which time he called EMS.

Context: While in the hospital, the patient is confused and cannot provide a history.

Context: He quickly loses consciousness and his CT scan is displayed in Figure 1.

Choices:
A. Subdural hematoma
B. Epidural hematoma
C. Subgaleal hematoma
D. Caput succedaneum

Answer: Epidural hematoma

1. A 35-year-old was brought into the emergency room.

2. The patient was involved in a bicycle vs motored vehicle accident.

3. He was unconscious after hitting the side of his head on the road.

4. He recovered consciousness after a few minutes.

5. He started to ride his bicycle again.

6. He then developed a severe headache with nausea and vomiting.

8. While in the hospital, the patient was confused and could not provide a history.

10. His CT scan is displayed in Figure 1.

1. He was unconscious after hitting the side of his head on the road.

2. He recovered consciousness after a few minutes.

3. He started to ride his bicycle again.

4. He developed a severe headache with nausea and vomiting.

5. He called EMS at the time of developing severe symptoms.

6. While in the hospital, the patient is confused.

9. His CT scan is displayed in Figure 1.


Question: Which of the following auscultation findings is most likely to correlate with the severity of this patient's valvular disease?

Context: A 39-year-old man comes to the physician because of a 2-month history of shortness of breath with exertion.

Context: His pulse is 88/min, respirations are 18/min, and blood pressure is 120/80 mm Hg.

Context: Echocardiography shows thickened mitral valve leaflets with reduced motion and a narrowed mitral valve orifice diameter.

Choices:
A. Decreased time between S2 and opening snap
B. Radiation of murmur to the axilla
C. Increased intensity of the murmur
D. Absence of A2 heart sound

Answer: Decreased time between S2 and opening snap

Cardiovascular Disease
Valvular Heart Disease
General Cardiology

1. A 39-year-old man comes to the physician.

2. He has a 2-month history of shortness of breath with exertion.

3. He immigrated to the United States from Ghana 20 years ago.

7. Echocardiography shows thickened mitral valve leaflets.

8. Echocardiography shows reduced motion of the mitral valve leaflets.

9. Echocardiography shows a narrowed mitral valve orifice diameter.

1. He immigrated to the United States from Ghana 20 years ago.

5. Echocardiography shows thickened mitral valve leaflets.

6. Echocardiography shows reduced motion of the mitral valve.

7. Echocardiography shows a narrowed mitral valve orifice diameter.


Question: Analysis of the bone marrow aspirate of this patient is most likely to show which of the following findings?

Context: A 6-year-old boy is brought to the physician because of worsening fatigue for the past 4 weeks.

Context: Examination of the head and neck shows conjunctival pallor, grayish-brown spots on the irises, prominent epicanthal folds, and a broad nasal bridge.

Context: He has a single transverse palmar crease, and there are scattered petechiae over the chest.

Choices:
A. Translocation t(15;17)
B. Ringed sideroblasts
C. CD10 positive cells
D. Hypocellular bone marrow

Answer: CD10 positive cells

1. A 6-year-old boy is brought to the physician.

2. The boy has been experiencing worsening fatigue for the past 4 weeks.

3. Examination of the head and neck shows conjunctival pallor.

4. Examination of the head and neck shows grayish-brown spots on the irises.

5. Examination of the head and neck shows prominent epicanthal folds.

6. Examination of the head and neck shows a broad nasal bridge.

7. The boy has a single transverse palmar crease.

8. There are scattered petechiae over the chest.

9. An ultrasound of the abdomen shows enlargement of the liver.

10. An ultrasound of the abdomen shows enlargement of the spleen.

1. Examination of the head and neck shows conjunctival pallor.

2. Examination of the head and neck shows grayish-brown spots on the irises.

3. Examination of the head and neck shows prominent epicanthal folds.

4. Examination of the head and neck shows a broad nasal bridge.

5. He has a single transverse palmar crease.

6. There are scattered petechiae over the chest.

7. An ultrasound of the abdomen shows enlargement of the liver and spleen.


Question: What is the diagnosis in this patient?

Context: A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever.

Context: The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks.

Context: The patient is noticeably jaundiced.

Context: Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL.

Choices:
A. Acute pancreatitis
B. Chronic pancreatitis
C. Acute cholangitis
D. Primary sclerosing cholangitis

Answer: Acute cholangitis

1. A 42-year-old female presents to the emergency department.

2. She has two days of severe abdominal pain and fever.

4. She was scheduled to have a cholecystectomy in two weeks.

5. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding.

7. Laboratory evaluation is notable for a leukocytosis.

8. Laboratory evaluation is notable for a total bilirubin of 6.4 mg/dL.

1. The patient has a history of gallstones.

2. The patient was scheduled to have a cholecystectomy in two weeks.

3. On physical exam, the patient's abdomen is tender to palpation over the epigastrium.

4. There is no rebound or guarding on physical exam.

6. Laboratory evaluation shows leukocytosis.

7. Laboratory evaluation shows a total bilirubin of 6.4 mg/dL.


Question: Which of the following characteristics of this patient most likely increased her risk for this disorder?

Context: A 52-year-old woman presents to her primary care physician because she has been feeling pain in her right leg.

Context: She also has been taking estrogen replacement therapy and drinking alcohol to cope with her symptoms of menopause.

Context: This lesion feels thick and hardened on palpation and is tender to the touch.

Context: She is started on compression therapy as well as NSAIDs for pain management.

Choices:
A. Alcohol use
B. Diabetes
C. Estrogen therapy
D. Hypertension

Answer: Estrogen therapy

1. A 52-year-old woman presents to her primary care physician.

2. She has been feeling pain in her right leg.

3. Specifically, she says that an area on her right thigh has been feeling tender and swollen over the past few weeks.

4. Her past medical history is significant for obesity, poorly controlled diabetes, and hypertension.

5. She has been taking estrogen replacement therapy.

6. She has been drinking alcohol to cope with her symptoms of menopause.

7. Her family history is significant for cardiomyopathy.

8. On physical exam, there is erythema and edema along a cord-like lesion in her thigh.

9. This lesion feels thick and hardened on palpation.

11. She is started on compression therapy.

12. She is started on NSAIDs for pain management.

1. The patient reports tenderness and swelling in an area on her right thigh.

2. The patient has a past medical history of obesity, poorly controlled diabetes, and hypertension.

3. The patient has been taking estrogen replacement therapy and drinking alcohol to cope with menopausal symptoms.

4. The patient's family history includes cardiomyopathy.

5. On physical exam, there is erythema and edema along a cord-like lesion in her thigh.

6. The lesion feels thick and hardened on palpation and is tender to the touch.

7. The patient is started on compression therapy and NSAIDs for pain management.


Question: What medication did the patient take?

Context: A 34-year-old woman presents to the clinic complaining of constipation and dry mouth.

Context: She had uncontrollable diarrhea for 1 day and took some medications afterwards.

Context: She also denies melena, hematochezia, nausea, or vomiting.

Context: Vitals are within normal limits.

Choices:
A. Loperamide
B. Oral vancomycin
C. Sulfasalazine
D. Setraline

Answer: Loperamide

1. A 34-year-old woman presents to the clinic.

2. She is complaining of constipation and dry mouth.

3. She had uncontrollable diarrhea for 1 day.

4. She took some medications afterwards.

5. Patient denies any recent hospitalizations or antibiotic use.

6. Patient denies melena, hematochezia, nausea, or vomiting.

1. The patient had uncontrollable diarrhea for 1 day.

2. The patient took some medications afterwards.

3. The patient denies any recent hospitalizations.

4. The patient denies any recent antibiotic use.

9. The patient's vitals are within normal limits.


Question: What is the most likely cause of this patient’s high blood pressure?

Context: A 25-year-old arrives at a gynecology clinic for a consult as she and her husband plan to conceive a baby soon.

Context: She is currently taking no medications, doesn’t smoke, and drinks alcohol socially.

Context: Her vital signs include blood pressure 150/100 mm Hg, heart rate 67/min, respiratory rate 16/min, and temperature 36.7°C (98.0°F).

Context: Physical examination is unremarkable.

Context: When asked about her high blood pressure, the patient says that her primary care physician once told her that her blood pressure was elevated on most of her visits; the physician emphasized that she should exercise and control her diet, but she never followed up with him as she always felt good.

Choices:
A. Atherosclerosis
B. Adult polycystic kidney disease
C. Fibromuscular hyperplasia
D. Pheochromocytoma

Answer: Fibromuscular hyperplasia

1. A 25-year-old is at a gynecology clinic for a consult.

2. The patient and her husband plan to conceive a baby soon.

3. The patient is not taking any medications.

6. The patient's father passed away at the age of 51 due to heart failure.

7. The patient's blood pressure is 150/100 mm Hg.

9. The patient's respiratory rate is 16/min.

10. The patient's temperature is 36.7°C (98.0°F).

11. The physical examination is unremarkable.

12. The patient's primary care physician told her that her blood pressure was elevated on most of her visits.

13. The primary care physician emphasized that the patient should exercise and control her diet.

14. The patient never followed up with her primary care physician as she always felt good.

15. Tests are run to find out the etiology of the patient's elevated blood pressure.

16. Everything is within the normal range except for a renal angiogram shown in the picture.

1. She is currently taking no medications.

4. Her father passed away at the age of 51 due to heart failure.

5. Her vital signs include blood pressure 150/100 mm Hg.

9. Physical examination is unremarkable.

10. The patient's primary care physician once told her that her blood pressure was elevated on most of her visits.

11. The physician emphasized that she should exercise and control her diet.

12. She never followed up with her physician as she always felt good.

13. A number of tests are run to find out the etiology of her elevated blood pressure.

14. Everything is within the normal range except for a renal angiogram shown in the picture.


Question: Which of the following embryonic structures most likely gave rise to the thickening described here?

Context: Since part of this ligament lies over the part of the liver that needs to be resected, the ligament is incised to allow for removal of the tumor.

Choices:
A. Ductus venosus
B. Left umbilical vein
C. Right umbilical artery
D. Ductus arteriosus

Answer: Left umbilical vein

1. A 73-year-old man is found to have an early stage hepatocellular carcinoma in the left lobe of his liver.

2. He decides to undergo surgery to remove the tumor through partial liver resection.

3. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.

4. Part of this ligament lies over the part of the liver that needs to be resected.

5. The ligament is incised to allow for removal of the tumor.

6. The free edge of the ligament is found to have a thickening.

7. The thickening has small remnant blood vessels.

1. He decides to undergo surgery to remove the tumor through partial liver resection.

2. During the procedure, a ligament is found that attaches the liver to the anterior abdominal wall.

3. Part of the ligament lies over the part of the liver that needs to be resected.

4. The ligament is incised to allow for removal of the tumor.

5. The free edge of the ligament is found to have a thickening with small remnant blood vessels.


Question: Which of the following parameters are most likely to affect the x-axis in the diagram?

Context: He documents specific observations and plots some of them as a Darrow-Yannet diagram.

Context: In his study, some diagrams are normal, while most are abnormal.

Context: The abnormalities in the diagram are mostly in the form of changes in the x-axis, changes in the y-axis or changes in both axes of the diagram.

Choices:
A. Fluid osmolality
B. Fluid surface tension
C. Fluid viscosity
D. Fluid volume

Answer: Fluid volume

1. A researcher is conducting an experiment on the physiology of body fluids.

3. He plots some of the observations as a Darrow-Yannet diagram.

6. The abnormalities in the diagram are mostly in the form of changes in the x-axis.

7. The abnormalities in the diagram are mostly in the form of changes in the y-axis.

8. The abnormalities in the diagram are mostly in the form of changes in both axes of the diagram.

2. He plots some observations as a Darrow-Yannet diagram.

3. In his study, some diagrams are normal.

4. Most diagrams in his study are abnormal.

5. The abnormalities in the diagram are mostly in the form of changes in the x-axis.

6. The abnormalities in the diagram are mostly in the form of changes in the y-axis.

7. The abnormalities in the diagram are mostly in the form of changes in both axes of the diagram.


Question: Which of the following drugs is most likely suggested by the pediatrician?

Context: An 11-year-old girl is brought to a pediatrician by her parents with recurrent wheezing for the last 3 years.

Context: After a detailed history, complete physical examination, and thorough diagnostic evaluation, the pediatrician informs the parents that the girl has mild persistent asthma, which will be most effectively treated with inhaled corticosteroids (ICS).

Context: However, her parents firmly object to the use of corticosteroids in any form, despite being told that the side effects associated with ICS are negligible.

Context: Therefore, the pediatrician suggests the regular use of a drug that does not contain a corticosteroid.

Context: The pediatrician mentions that the drug is used as prophylaxis only and will not be useful to treat acute bronchospasm.

Choices:
A. Subcutaneous terbutaline
B. Inhaled ipratropium bromide
C. Inhaled cromolyn sodium
D. Oral roflumilast

Answer: Inhaled cromolyn sodium

1. An 11-year-old girl is brought to a pediatrician by her parents.

2. The girl has had recurrent wheezing for the last 3 years.

3. The pediatrician has conducted a detailed history, complete physical examination, and thorough diagnostic evaluation.

4. The pediatrician has informed the parents that the girl has mild persistent asthma.

5. The most effective treatment for the girl's asthma is inhaled corticosteroids (ICS).

6. The parents object to the use of corticosteroids in any form.

7. The pediatrician has informed the parents that the side effects associated with ICS are negligible.

8. The pediatrician has suggested the regular use of a drug that does not contain a corticosteroid.

9. The drug is used as prophylaxis only and will not be useful to treat acute bronchospasm.

2. The most effective treatment for her asthma is inhaled corticosteroids (ICS).

3. The parents object to the use of corticosteroids in any form.

4. The side effects associated with ICS are negligible.

5. The pediatrician suggests the regular use of a drug that does not contain a corticosteroid.

6. The drug is used as prophylaxis only.

7. The drug will not be useful to treat acute bronchospasm.


Question: Based on this knowledge, provided the concentration and actions of reactant B and enzyme E are same in both normal hepatocytes and hepatocytes of fatty liver patients, which of the following is the most likely possibility if drug A is administered to hypertensive patients with fatty liver?

Context: A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients by a novel mechanism of action.

Context: The drug A is an inactive prodrug and enters hepatocytes, reacts with reactant B, a native material in the cell, and creates products C and D.

Context: D has a blood pressure lowering effects.

Context: The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes whereas, in hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason.

Choices:
A. Drug A will decrease blood pressure only if reactant B is also supplemented in necessary dose
B. Drug A will decrease blood pressure only if enzyme E is also supplemented in necessary dose
C. Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E
D. Drug A will decrease blood pressure in same dose as required for patients with a healthy liver

Answer: Drug A will not decrease blood pressure, regardless of its dose or supplementation of B or E

1. A team of scientists is researching the synthesis of a drug that would potentially reduce blood pressure in hypertensive patients.

2. The drug A is an inactive prodrug and enters hepatocytes.

3. The drug A reacts with reactant B, a native material in the cell.

4. The reaction creates products C and D.

5. Product D has a blood pressure lowering effect.

6. The reaction requires the presence of enzyme E.

7. The researcher observes that, for the above chemical reaction, Gibbs free energy change (ΔG) is less than zero in normal hepatocytes.

8. In hepatocytes of patients with fatty liver, ΔG is more than 0 due to some unknown reason.

4. Reactant B is a native material in the cell.

5. The reaction of A and B creates products C and D.

6. Product D has blood pressure lowering effects.

7. The reaction requires the presence of enzyme E.

8. In normal hepatocytes, the Gibbs free energy change (ΔG) for the reaction is less than zero.

9. In hepatocytes of patients with fatty liver, ΔG for the reaction is more than 0.

10. The reason for the change in ΔG in fatty liver patients is unknown.


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

Context: A 70-year-old man comes to the physician because of a 4-month history of progressively worsening lower back pain.

Context: He describes the pain as a constant, dull ache that interferes with his sleep and is only partially relieved with ibuprofen.

Context: Two years ago, he was diagnosed with advanced prostate cancer, for which he underwent radiation therapy of the prostate and bilateral orchiectomy.

Context: He missed his previous follow-up visit.

Context: Vital signs are within normal limits.

Context: The serum PSA concentration is 16 ng/mL (N<4).

Context: A technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies.

Choices:
A. External beam radiotherapy to the lumbar vertebrae
B. Leuprolide therapy
C. Finasteride therapy
D. Observation with no further treatment

Answer: External beam radiotherapy to the lumbar vertebrae

2. Patient has 4-month history of progressively worsening lower back pain.

3. Patient describes pain as constant, dull ache.

4. Pain interferes with sleep and is only partially relieved with ibuprofen.

5. Two years ago, patient was diagnosed with advanced prostate cancer.

6. Patient underwent radiation therapy of the prostate and bilateral orchiectomy.

7. One year postoperatively, serum prostate-specific antigen (PSA) was undetectable.

8. Patient missed previous follow-up visit.

9. Current medications include over-the-counter ibuprofen.

10. Vital signs are within normal limits.

11. Physical examination shows tenderness of the spinous process of the third lumbar vertebra.

12. Digital rectal examination shows a hard, nontender prostate.

13. The remainder of the examination shows no abnormalities.

14. Serum PSA concentration is 16 ng/mL (N<4).

15. Technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies.

1. Patient describes pain as constant, dull ache interfering with sleep

2. Pain partially relieved with ibuprofen

3. Diagnosed with advanced prostate cancer two years ago

4. Underwent radiation therapy of the prostate and bilateral orchiectomy

5. One year postoperatively, serum PSA was undetectable

7. Current medications include over-the-counter ibuprofen

9. Physical examination shows tenderness of the spinous process of the third lumbar vertebra

10. Digital rectal examination shows hard, nontender prostate

11. Remainder of the examination shows no abnormalities

12. Serum PSA concentration is 16 ng/mL (N<4)

13. Technetium-99m bone scan shows increased uptake at the second and third lumbar vertebral bodies