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

Context: A 2-year-old boy is brought to the physician by his parents because their son frequently avoids eye contact and has no friends in daycare.

Context: He was born at term and has been healthy except for an episode of otitis media 6 months ago.

Context: His immunizations are up-to-date.

Context: He is at the 95th percentile for height, 20th percentile for weight, and 95th percentile for head circumference.

Context: Vital signs are within normal limits.

Context: He continually opens and closes his mother's purse and does not maintain eye contact.

Choices:
A. CGG trinucleotide repeat expansion on X-chromosome
B. Deletion of the long arm on chromosome 7
C. Genomic imprinting on chromosome 15
D. An additional X chromosome

Answer: CGG trinucleotide repeat expansion on X-chromosome

1. A 2-year-old boy is brought to the physician by his parents.

2. The boy frequently avoids eye contact and has no friends in daycare.

4. He has been healthy except for an episode of otitis media 6 months ago.

6. He is at the 95th percentile for height.

7. He is at the 20th percentile for weight.

8. He is at the 95th percentile for head circumference.

9. Vital signs are within normal limits.

10. Examination shows elongated facial features and large ears.

11. The patient is shy and does not speak or follow instructions.

12. He continually opens and closes his mother's purse.

2. He has been healthy except for an episode of otitis media 6 months ago.

4. He is at the 95th percentile for height.

5. He is at the 20th percentile for weight.

6. He is at the 95th percentile for head circumference.

7. Vital signs are within normal limits.

8. Examination shows elongated facial features and large ears.

10. The patient does not speak or follow instructions.

11. He continually opens and closes his mother's purse.


Question: What best explains the change in this patient’s lipid profile over this time period?

Context: His lab results from 1 week ago and from his day of admission to hospital are as follows: | 7 days ago | On admission to hospital | Serum glucose (random)  130 mg/dL | Serum electrolytes | Sodium 142 mEq/L | Potassium 3.9 mEq/L | Chloride 101 mEq/L | Serum creatinine 0.8 mg/dL | Blood urea nitrogen 9 mg/dL | Cholesterol, total 170 mg/dL | HDL-cholesterol 42 mg/dL | LDL-cholesterol 110 mg/dL | Triglycerides 130 mg/dL | Serum glucose (random)  100 mg/dL | Serum electrolytes | Sodium 140 mEq/L | Potassium 4.0 mEq/L | Chloride 100 mEq/L | Serum creatinine 0.9 mg/dL | Blood urea nitrogen 11 mg/dL | Cholesterol, total 130 mg/dL | HDL-cholesterol 30 mg/dL | LDL-cholesterol 80 mg/dL | Triglycerides 180 mg/dL | .

Choices:
A. COPD exacerbation
B. Drug side effect
C. Physiological response
D. Undiagnosed dyslipidemia

Answer: Physiological response

1. A 78-year-old man is admitted to hospital for treatment of a severe attack of pneumonia he has been experiencing for the past three days.

2. A week earlier, he had been feeling well until he developed what he describes as a mild cold.

3. Over the next few days, he began to have difficulty breathing and developed a productive cough and fever.

4. As his condition worsened despite antibiotic therapy at home, he was admitted for intravenous antibiotics and observation.

5. He has a 50-pack-year history of smoking and has been diagnosed with chronic obstructive pulmonary disease (COPD).

6. Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.

7. He has been drinking 3 alcoholic drinks daily for the last 60 years and smoked marijuana during his 20s.

8. His lab results from 1 week ago show a serum glucose (random) of 130 mg/dL, sodium of 142 mEq/L, potassium of 3.9 mEq/L, chloride of 101 mEq/L, serum creatinine of 0.8 mg/dL, and blood urea nitrogen of 9 mg/dL.

9. His lab results from his day of admission to hospital show a serum glucose (random) of 100 mg/dL, sodium of 140 mEq/L, potassium of 4.0 mEq/L, chloride of 100 mEq/L, serum creatinine of 0.9 mg/dL, and blood urea nitrogen of 11 mg/dL.

10. His lab results from 1 week ago show a cholesterol, total of 170 mg/dL, HDL-cholesterol of 42 mg/dL, LDL-cholesterol of 110 mg/dL, and triglycerides of 130 mg/dL.

11. His lab results from his day of admission to hospital show a cholesterol, total of 130 mg/dL, HDL-cholesterol of 30 mg/dL, LDL-cholesterol of 80 mg/dL, and triglycerides of 180 mg/dL.

1. The patient had been feeling well a week earlier.

2. He developed what he describes as a mild cold.

3. He began to have difficulty breathing over the next few days.

4. He developed a productive cough and fever.

5. His condition worsened despite antibiotic therapy at home.

6. He was admitted for intravenous antibiotics and observation.

7. The patient has a 50-pack-year history of smoking.

8. He has been diagnosed with chronic obstructive pulmonary disease (COPD).

9. Prior to admission, the man was taking inhaled formoterol, budesonide, and oxygen at home.

10. He has been drinking 3 alcoholic drinks daily for the last 60 years.

12. His lab results from 1 week ago and from his day of admission to hospital are as follows:

13. Serum glucose (random) 130 mg/dL 7 days ago.

14. Serum electrolytes: Sodium 142 mEq/L, Potassium 3.9 mEq/L, Chloride 101 mEq/L, Serum creatinine 0.8 mg/dL, Blood urea nitrogen 9 mg/dL, Cholesterol, total 170 mg/dL, HDL-cholesterol 42 mg/dL, LDL-cholesterol 110 mg/dL, Triglycerides 130 mg/dL 7 days ago.

15. Serum glucose (random) 100 mg/dL on admission to hospital.

16. Serum electrolytes: Sodium 140 mEq/L, Potassium 4.0 mEq/L, Chloride 100 mEq/L, Serum creatinine 0.9 mg/dL, Blood urea nitrogen 11 mg/dL, Cholesterol, total 130 mg/dL, HDL-cholesterol 30 mg/dL, LDL-cholesterol 80 mg/dL, Triglycerides 180 mg/dL on admission to hospital.


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

Context: A 42-year-old woman comes to the physician because of a 4-week history of progressive difficulty swallowing solid foods.

Context: The patient reports feeling like food gets stuck in her throat, and that she has to drink a lot of water to swallow her meals.

Context: Over the past 3 months, she has had progressive fatigue and occasional dyspnea while performing her daily activities.

Context: Her pulse is 104/min, respirations are 19/min, and blood pressure is 110/70 mm Hg.

Context: Physical examination shows conjunctival pallor, erythema around the corners of the mouth, and dry, scaly lips.

Context: Her fingernails appear spoon-shaped and brittle.

Choices:
A. Altered sense of smell
B. Intolerance to cold temperatures
C. Thickening of the skin
D. Craving for non-nutritive substances

Answer: Craving for non-nutritive substances

2. Patient has had difficulty swallowing solid foods for 4 weeks.

3. Patient feels like food gets stuck in her throat.

4. Patient has to drink a lot of water to swallow meals.

5. Patient has had progressive fatigue for 3 months.

6. Patient has occasional dyspnea while performing daily activities.

9. Patient's blood pressure is 110/70 mm Hg.

10. Physical examination shows conjunctival pallor.

11. Physical examination shows erythema around the corners of the mouth.

12. Physical examination shows dry, scaly lips.

13. Patient's fingernails appear spoon-shaped and brittle.

14. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.

15. Esophagogastroduodenoscopy shows thin membranes that are protruding into the upper third of the esophagus.

1. The patient reports feeling like food gets stuck in her throat.

2. The patient reports having to drink a lot of water to swallow her meals.

3. Over the past 3 months, the patient has had progressive fatigue.

4. Over the past 3 months, the patient has had occasional dyspnea while performing her daily activities.

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

7. The patient's blood pressure is 110/70 mm Hg.

8. Physical examination shows conjunctival pallor.

9. Physical examination shows erythema around the corners of the mouth.

10. Physical examination shows dry, scaly lips.

11. The patient's fingernails appear spoon-shaped.

12. The patient's fingernails appear brittle.

13. Auscultation of the heart shows a grade 1/6 systolic murmur best heard at the second left intercostal space.

14. Esophagogastroduodenoscopy shows thin membranes protruding into the upper third of the esophagus.


Question: Which of the following statements regarding the management of this patient is correct?

Context: A 27-year-old nullipara makes an appointment with her gynecologist to discuss the results of her cervical cancer screening.

Context: She is not vaccinated against HPV and has a single sexual partner.

Context: She and her partner are planning pregnancy, so she recently discontinued oral contraception and began to take folate and iron supplements.

Context: Her first Pap smear showed atypical squamous cells of undetermined significance, but 2 subsequent Pap smears had normal results.

Context: Colposcopy was performed at the next visit and a biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.

Context: The pathologic assessment shows CIN 3.

Choices:
A. The annual rate of progression of CIN 3 to cancer is > 10%, so the patient should be treated as soon as possible.
B. Close follow-up with cytology and colposcopy may be considered in this patient.
C. Additional HPV testing would be useful to guide the therapy.
D. Pregnancy is not recommended in women with high-grade cervical lesions, so treatment is reasonable.

Answer: Close follow-up with cytology and colposcopy may be considered in this patient.

1. A 27-year-old nullipara makes an appointment with her gynecologist.

4. She and her partner are planning pregnancy.

5. She recently discontinued oral contraception.

6. She began to take folate and iron supplements.

7. She has no history of gynecologic diseases.

8. Her first Pap smear showed atypical squamous cells of undetermined significance.

9. Two subsequent Pap smears had normal results.

10. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.

11. Colposcopy was performed at the next visit.

12. A biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.

13. The pathologic assessment shows CIN 3.

3. She recently discontinued oral contraception.

4. She began to take folate and iron supplements.

5. She has no history of gynecologic diseases.

6. Her first Pap smear showed atypical squamous cells of undetermined significance.

7. 2 subsequent Pap smears had normal results.

8. The most recent Pap smear was reported as a high-grade squamous intraepithelial lesion.

9. Colposcopy was performed at the next visit.

10. A biopsy was obtained from a small patch of the acetowhite epithelium at the cervical transformation zone.

11. The pathologic assessment shows CIN 3.


Question: Which of the following findings most closely correlates with this patient's symptoms?

Context: A 47-year-old woman comes to the physician because of a 3-month history of recurrent episodes of nausea and feeling like the room is spinning.

Context: Each episode lasts less than a minute and usually occurs when she gets out of bed in the morning or suddenly turns her head.

Context: She has not vomited and does not have headaches.

Context: She is asymptomatic between episodes.

Choices:
A. Intention tremor
B. Nystagmus
C. Abnormal Rinne test
D. Orthostatic hypotension

Answer: Nystagmus

Neurology with Special Qualification in Child Neurology

1. A 47-year-old woman comes to the physician.

2. She has a 3-month history of recurrent episodes of nausea.

3. She also has a feeling like the room is spinning.

4. Each episode lasts less than a minute.

5. The episodes usually occur when she gets out of bed in the morning or suddenly turns her head.

8. She is asymptomatic between episodes.

1. Each episode lasts less than a minute.

2. Episodes usually occur when she gets out of bed in the morning.

3. Episodes also occur when she suddenly turns her head.

6. She is asymptomatic between episodes.


Question: Which of the following is the most likely precipitating factor for this patient's symptoms?

Context: A 56-year-old man is brought to the emergency department by his wife because of increasing confusion and lethargy for the past 12 hours.

Context: He is oriented only to person.

Context: His temperature is 37.3°C (99.1°F), pulse is 109/min, respirations are 18/min, and blood pressure is 108/67 mm Hg.

Context: Examination shows abdominal distention and several erythematous, lacy lesions on the chest that blanch with pressure.

Choices:
A. Elevated systemic vascular resistance
B. Destruction of gut anaerobes
C. Presence of hemoglobin in the intestine
D. Low protein consumption

Answer: Presence of hemoglobin in the intestine

1. A 56-year-old man is brought to the emergency department by his wife.

2. He has been experiencing increasing confusion and lethargy for the past 12 hours.

8. Examination shows abdominal distention.

9. Examination shows several erythematous, lacy lesions on the chest.

10. The lesions on the chest blanch with pressure.

11. His hands make a flapping motion when they are dorsiflexed.

6. Examination shows abdominal distention.

7. Examination shows several erythematous, lacy lesions on the chest that blanch with pressure.

8. His hands make a flapping motion when they are dorsiflexed.


Question: The patient was most likely treated with a drug that predominantly acts on which of the following parts of the cell?

Context: A 63-year-old man comes to the physician because of a 4-hour history of severe pain in the right knee.

Context: His temperature is 38.0°C (100.1°F).

Context: Examination shows erythema, edema, and warmth of the right knee; range of motion is limited by pain.

Context: Arthrocentesis of the knee joint yields cloudy fluid with a leukocyte count of 24,000/mm3 (74% segmented neutrophils).

Choices:
A. Cell wall
B. Cytosolic enzyme
C. Nucleus
D. Cytoskeleton

Answer: Cytoskeleton

1. A 63-year-old man comes to the physician.

2. He has a 4-hour history of severe pain in the right knee.

4. Examination shows erythema, edema, and warmth of the right knee.

6. Arthrocentesis of the knee joint yields cloudy fluid.

7. Leukocyte count of the fluid is 24,000/mm3 (74% segmented neutrophils).

8. Polarized light microscopy shows needle-shaped, negatively birefringent crystals.

9. Five hours after treatment with a drug is begun, he develops abdominal cramp.

2. Examination shows erythema, edema, and warmth of the right knee.

4. Arthrocentesis of the knee joint yields cloudy fluid.

5. The leukocyte count of the fluid is 24,000/mm3.

6. 74% of the leukocytes are segmented neutrophils.

7. Polarized light microscopy shows needle-shaped, negatively birefringent crystals.

8. Five hours after treatment with a drug is begun, he develops abdominal cramp, diarrhea, and vomiting.


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

Context: A 1-year-old boy presents to the emergency department for several days of irritability and poor feeding.

Context: His parents are very concerned that he has been acting differently.

Context: The patient has an unremarkable past medical history and has been followed by a pediatrician.

Context: His temperature is 102°F (38.9°C), blood pressure is 57/38 mmHg, pulse is 170/min, respirations are 35/min, and oxygen saturation is 99% on room air.

Context: Fundoscopy is within normal limits.

Choices:
A. Blood and urine cultures
B. Lumbar puncture
C. Vancomycin and ceftriaxone
D. Vancomycin, ceftriaxone, and prednisone

Answer: Lumbar puncture

Pediatric Infectious Diseases
General Pediatrics

1. A 1-year-old boy presents to the emergency department.

2. The parents are concerned that he has been acting differently.

3. The patient has an unremarkable past medical history.

4. The patient has been followed by a pediatrician.

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

6. The patient's blood pressure is 57/38 mmHg.

8. The patient's respirations are 35/min.

9. The patient's oxygen saturation is 99% on room air.

10. During the exam the infant is irritable and is crying.

11. Musculoskeletal exam reveals that the patient's knee can not be extended while the patient's hip is in a flexed position without significant patient irritation.

13. Abdominal, cardiac, and pulmonary exam are within normal limits.

1. The patient's parents are very concerned about his change in behavior.

2. The patient has an unremarkable past medical history.

3. The patient has been followed by a pediatrician.

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

5. The patient's blood pressure is 57/38 mmHg.

7. The patient's respirations are 35/min.

8. The patient's oxygen saturation is 99% on room air.

9. During the exam, the infant is irritable and crying.

10. The patient's knee cannot be extended while the hip is in a flexed position without significant irritation.

12. Abdominal exam is within normal limits.

13. Cardiac exam is within normal limits.

14. Pulmonary exam is within normal limits.


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

Context: A 74-year-old man comes to the physician because of a 2-month history of shortness of breath and leg swelling.

Context: He has hypertension and was diagnosed with multiple myeloma 6 months ago.

Context: Cardiopulmonary examination shows jugular venous distention, bibasilar crackles, and pitting edema in the lower extremities.

Context: Transthoracic echocardiography shows a thickened myocardium with elevated diastolic filling pressures.

Choices:
A. Chronic vasoconstriction
B. Myosin gene mutation
C. Amyloid deposition
D. Chronic hypercalcemia

Answer: Amyloid deposition

Cardiovascular Disease
Cardiology
General Cardiology

1. A 74-year-old man comes to the physician.

2. He has a 2-month history of shortness of breath and leg swelling.

3. He has trouble climbing one flight of stairs due to dyspnea.

5. He was diagnosed with multiple myeloma 6 months ago.

6. His current medications include hydrochlorothiazide.

7. Cardiopulmonary examination shows jugular venous distention.

8. Cardiopulmonary examination shows bibasilar crackles.

9. Cardiopulmonary examination shows pitting edema in the lower extremities.

10. Transthoracic echocardiography shows a thickened myocardium.

11. Transthoracic echocardiography shows elevated diastolic filling pressures.

1. He has trouble climbing one flight of stairs due to dyspnea.

3. He was diagnosed with multiple myeloma 6 months ago.

4. Current medications include hydrochlorothiazide.

5. Cardiopulmonary examination shows jugular venous distention.

6. Cardiopulmonary examination shows bibasilar crackles.

7. Cardiopulmonary examination shows pitting edema in the lower extremities.

8. Transthoracic echocardiography shows a thickened myocardium.

9. Transthoracic echocardiography shows elevated diastolic filling pressures.


Question: The next appropriate step in the management of this patient involves passing a tube through an incision through which of the following structures?

Context: A 47-year-old man is brought to the emergency department 30 minutes after he was involved in a motor vehicle collision.

Context: On arrival, he is unconscious and unresponsive to painful stimuli.

Context: His pulse is 120/min, respirations are 10/min, and his blood pressure is 88/60 mm Hg.

Context: Infusion of 0.9% saline is begun, and intubation is attempted without success.

Choices:
A. Investing layer of deep cervical fascia
B. Annular ligament
C. Cricotracheal ligament
D. Prevertebral layer of deep cervical fascia

Answer: Investing layer of deep cervical fascia

General Surgery
General Emergency Medicine

1. A 47-year-old man was brought to the emergency department 30 minutes after a motor vehicle collision.

2. On arrival, he was unconscious and unresponsive to painful stimuli.

7. Intubation was attempted without success.

8. Pulse oximetry on 20 L/min of oxygen via bag mask showed an oxygen saturation of 78%.

1. On arrival, the patient is unconscious.

2. On arrival, the patient is unresponsive to painful stimuli.

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

5. The patient's blood pressure is 88/60 mm Hg.

7. Intubation is attempted without success.

8. Pulse oximetry on 20 L/min of oxygen via bag mask shows an oxygen saturation of 78%.


Question: What is the most likely diagnosis?

Context: Parents bring an 11-month-old baby to the clinic because the baby has a fever of 39.0°C (102.2°F).

Context: She is up to date on immunizations.

Context: A complete physical examination reveals no significant findings, and all laboratory tests are negative.

Choices:
A. Roseola
B. Erythema infectiosum
C. Rubella
D. Kawasaki disease

Answer: Roseola

1. Parents bring an 11-month-old baby to the clinic.

2. The baby has a fever of 39.0°C (102.2°F).

3. The baby is irritated and crying constantly.

4. The baby is up to date on immunizations.

5. A complete physical examination reveals no significant findings.

7. Five days after resolution of her fever, she develops a transient maculopapular rash.

4. A complete physical examination reveals no significant findings.

6. Five days after resolution of her fever, she develops a transient maculopapular rash.


Question: Which of the following statements would best explain the mechanism of action of these drugs?

Context: A 67-year-old man is brought to his primary care practitioner by his daughter who has noticed a ‘pill-rolling’ tremor in his right hand, along with a progressively slow, shuffling gait.

Context: The patient’s daughter says that these symptoms gradually started 2 weeks ago and have progressively worsened.

Context: His past medical history is significant for hypertension, which is well-controlled with losartan.

Context: He does not take any other medications.

Context: Physical examination reveals a slow shuffling gait, difficulty initiating movements, a resting tremor in his right hand that decreases in intensity with voluntary movement, and cogwheel-like rigidity in the right arm.

Choices:
A. Inhibition of the enzyme monoamine oxidase (MAO) B
B. Blockade of muscarinic receptors
C. Inhibition of dopamine reuptake
D. Increased dopamine synthesis

Answer: Increased dopamine synthesis

2. Patient's daughter noticed a "pill-rolling" tremor in his right hand.

3. Patient's daughter noticed a progressively slow, shuffling gait.

4. Symptoms gradually started 2 weeks ago and have progressively worsened.

5. Patient has a past medical history of hypertension.

6. Hypertension is well-controlled with losartan.

7. Patient does not take any other medications.

8. Physical examination reveals a slow shuffling gait.

9. Physical examination reveals difficulty initiating movements.

10. Physical examination reveals a resting tremor in his right hand that decreases in intensity with voluntary movement.

11. Physical examination reveals cogwheel-like rigidity in the right arm.

12. Primary care practitioner decides to prescribe levodopa and carbidopa.

1. The patient's daughter reports that symptoms started 2 weeks ago and have worsened.

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

3. The hypertension is well-controlled with losartan.

4. The patient does not take any other medications.

5. Physical examination reveals a slow shuffling gait.

6. Physical examination reveals difficulty initiating movements.

7. Physical examination reveals a resting tremor in the right hand.

8. The tremor decreases in intensity with voluntary movement.

9. Physical examination reveals cogwheel-like rigidity in the right arm.

10. The primary care practitioner decides to prescribe levodopa and carbidopa.


Question: Which of the following is the most likely underlying pathogenesis?

Context: A 79-year-old man with a long-standing history of hypertension and diabetes presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.

Context: MRI of the brain is obtained and shows a small sub-cortical infarct involving a perforating vessel.

Choices:
A. Embolism originating from the left atrium
B. Berry aneurysm
C. Lipohyalinosis of small vessels
D. Fibromuscular dysplasia

Answer: Lipohyalinosis of small vessels

2. Patient has a long-standing history of hypertension and diabetes.

3. Patient presents to the emergency department with sudden-onset of loss of motor function on the left side of his body.

4. Neurologic exam shows normal sensation throughout the body.

6. MRI of the brain shows a small sub-cortical infarct involving a perforating vessel.

1. Neurologic exam shows normal sensation throughout the body.

3. MRI shows a small sub-cortical infarct.

4. The infarct involves a perforating vessel.


Question: If the cardiologist was aware of Berkson’s bias (also known as the admission rate bias), he could minimize it by which of the following?

Context: A cardiology specialist working in the university hospital center noticed that a large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.

Context: In order to determine whether a relationship existed between myocardial infarction and malignant processes, he decided to pursue a case-control study.

Context: His selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction, while control cases were patients on the same ward without a history of a myocardial infarction.

Choices:
A. Including the diagnoses negatively related to the risk factor being studied
B. Excluding controls that present a probability of hospital admission similar to cases
C. Recruiting the controls from different wards to increase disease variability
D. Excluding those patients with preferential recollection of exposures

Answer: Recruiting the controls from different wards to increase disease variability

1. A cardiology specialist was working in the university hospital center.

2. A large number of his patients who had myocardial infarctions also had some sort of malignancy in their medical history.

3. He decided to pursue a case-control study to determine whether a relationship existed between myocardial infarction and malignant processes.

4. The selected cases consisted of a sample of patients hospitalized in an internal ward with a history of a myocardial infarction.

5. The control cases were patients on the same ward without a history of a myocardial infarction.

6. Their charts and medical documentation were then reviewed for a history of any type of malignancy.

7. The results of the study led the cardiologist to conclude that, for patients with malignancy, the odds of having a myocardial infarction were 3.2 times higher when compared to patients without malignancy.

1. The cardiologist pursued a case-control study to determine the relationship between myocardial infarction and malignant processes.

2. The selected cases for the study were patients hospitalized in an internal ward with a history of myocardial infarction.

3. The control cases for the study were patients on the same ward without a history of myocardial infarction.

4. Charts and medical documentation of the patients were reviewed for a history of any type of malignancy.

5. The study results showed that the odds of having a myocardial infarction were 3.2 times higher for patients with malignancy compared to patients without malignancy.


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

Context: A 27-year-old woman presents to her primary care physician’s office with fatigue, headaches, and concentration difficulties.

Context: Throughout this time, she reports problems with initiating and remaining asleep, has noticed periods of muscle soreness, and has feelings of restlessness.

Context: She states that she is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.

Context: She takes a daily multivitamin.

Context: She occasionally drinks alcohol during social gatherings, does not smoke, and denies any illicit drug use.

Context: Her temperature is 99°F (37.2 °C), blood pressure is 110/75, pulse is 101/min, and respirations are 18/min.

Context: Physical examination is unremarkable.

Choices:
A. Buspirone
B. Mirtazapine
C. Olanzapine
D. Trazodone

Answer: Buspirone

General Psychiatry
General Internal Medicine

1. A 27-year-old woman presents to her primary care physician's office.

2. She has fatigue, headaches, and concentration difficulties.

3. Her symptoms began approximately 7 months prior to presentation.

4. She reports problems with initiating and remaining asleep.

5. She has noticed periods of muscle soreness and has feelings of restlessness.

6. She is very concerned about whether she will be able to pay her monthly expenses and if her parents are satisfied with her career choices.

7. She is also worried about how her colleagues and supervisor think of her performance at work.

8. She denies any significant past medical history besides occasional palpitations.

10. Family history is significant for panic disorder in her mother.

11. She currently lives alone and at times socializes with friends.

12. She occasionally drinks alcohol during social gatherings.

13. She does not smoke and denies any illicit drug use.

18. Physical examination is unremarkable.

1. Her symptoms began approximately 7 months prior to presentation.

2. She reports problems with initiating and remaining asleep.

3. She has noticed periods of muscle soreness.

5. She is very concerned about whether she will be able to pay her monthly expenses.

6. She is concerned about if her parents are satisfied with her career choices.

7. She is worried about how her colleagues and supervisor think of her performance at work.

19. Physical examination is unremarkable.


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

Context: A 73-year-old man comes in to the emergency department because of nausea and severe pain in his upper abdomen and right shoulder blade for the past day.

Context: He appears acutely distressed.

Context: Laboratory studies show: | Hemoglobin 14.3 g/dL | Leukocyte count 18,100/mm3 | Platelet count 216,000/mm3 | Serum | Aspartate aminotransferase (AST, SGOT) 41 U/L | Alanine aminotransferase (ALT, SGPT) 19 U/L | Alkaline phosphatase 110 U/L | Total bilirubin 0.9 mg/dL | Direct bilirubin 0.2 mg/dL | Albumin 4.1 g/dL | Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.

Choices:
A. Chronic pancreatitis with pseudocyst rupture
B. Emphysematous cholecystitis
C. Gallstone ileus
D. Primary sclerosing cholangitis

Answer: Emphysematous cholecystitis

1. A 73-year-old man comes in to the emergency department.

2. He has nausea and severe pain in his upper abdomen and right shoulder blade for the past day.

3. He was able to eat a little for breakfast but vomited up the meal a couple of hours later.

4. He has type 2 diabetes mellitus treated with metformin.

5. He has smoked half a pack of cigarettes daily for 40 years.

11. Pulse oximetry on room air shows an oxygen saturation of 95%.

13. There is tenderness to palpation of the right upper quadrant with soft crepitus.

14. The remainder of the examination shows no abnormalities.

15. Laboratory studies show a hemoglobin of 14.3 g/dL.

16. Laboratory studies show a leukocyte count of 18,100/mm3.

17. Laboratory studies show a platelet count of 216,000/mm3.

18. Laboratory studies show an aspartate aminotransferase (AST, SGOT) of 41 U/L.

19. Laboratory studies show an alanine aminotransferase (ALT, SGPT) of 19 U/L.

20. Laboratory studies show an alkaline phosphatase of 110 U/L.

21. Laboratory studies show a total bilirubin of 0.9 mg/dL.

22. Laboratory studies show a direct bilirubin of 0.2 mg/dL.

23. Laboratory studies show an albumin of 4.1 g/dL.

24. Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.

1. He was able to eat a little for breakfast but vomited up the meal a couple of hours later.

2. He has type 2 diabetes mellitus treated with metformin.

3. He has smoked half a pack of cigarettes daily for 40 years and drinks 4 beers every week.

5. His temperature is 38.8°C (102°F), pulse is 124/min, and blood pressure is 92/68 mm Hg.

6. Pulse oximetry on room air shows an oxygen saturation of 95%.

7. The abdomen is soft and there is tenderness to palpation of the right upper quadrant with soft crepitus.

8. The remainder of the examination shows no abnormalities.

9. Laboratory studies show: Hemoglobin 14.3 g/dL, Leukocyte count 18,100/mm3, Platelet count 216,000/mm3, Serum Aspartate aminotransferase (AST, SGOT) 41 U/L, Alanine aminotransferase (ALT, SGPT) 19 U/L, Alkaline phosphatase 110 U/L, Total bilirubin 0.9 mg/dL, Direct bilirubin 0.2 mg/dL, Albumin 4.1 g/dL.

10. Ultrasonography of the right upper quadrant shows a gallbladder with an air-filled, thickened wall and no stones in the lumen.


Question: Which of the following is associated with his condition?

Context: On presentation to the clinic, the blood pressure is 190/110 mm Hg; the femoral pulse is reduced compared to the radial pulse, and an ejection click is heard.

Context: There was no murmur.

Choices:
A. Ventricular septal defect (VSD)
B. Wolff-Parkinson-White syndrome
C. Coarctation of the aorta
D. Atrial septal defect (ASD)

Answer: Coarctation of the aorta

1. A 26-year-old man presented with a headache and fatigue for the past few months.

2. On presentation to the clinic, the blood pressure is 190/110 mm Hg.

3. The femoral pulse is reduced compared to the radial pulse.

1. Blood pressure on presentation to the clinic is 190/110 mm Hg.

2. The femoral pulse is reduced compared to the radial pulse.


Question: Which of the following strategies is most likely to decrease the likelihood that the procedure will exacerbate the patient’s renal failure?

Context: A 57-year-old man with a history of diabetes and stage 3 chronic kidney disease is admitted to the hospital for elective coronary angiography.

Context: The senior resident admitting the patient to the ward is concerned about his chronic renal impairment and the scheduled angiography, which will require the use of intravenous contrast.

Choices:
A. Intravenous mannitol before and during the procedure
B. Intravenous N-acetyl cysteine before and during the procedure
C. Use non-iodinated contrast medium
D. Forced diuresis with furosemide

Answer: Use non-iodinated contrast medium

1. A 57-year-old man has a history of diabetes.

2. The man has stage 3 chronic kidney disease.

3. The man is admitted to the hospital for elective coronary angiography.

4. The senior resident admitting the patient is concerned about the man's chronic renal impairment.

5. The scheduled angiography will require the use of intravenous contrast.

1. The senior resident is admitting the patient to the ward.

2. The patient has chronic renal impairment.

3. The patient is scheduled for an angiography.

4. The angiography will require the use of intravenous contrast.


Question: Presuming it is an inherited condition, what is the most likely genetic pathophysiology of this disorder?

Context: A 17-year-old girl is brought in a wheelchair because of gradually progressive difficulty in walking, incoordination, and frequent falls.

Context: She later experienced difficulties with coordination, which later involved her arms and trunk.

Context: The physical examination reveals severely ataxic gait, nystagmus, absent deep tendon reflexes, and loss of vibration and proprioception.

Choices:
A. GAA trinucleotide repeats
B. Mitochondrial DNA mutation
C. NOTCH3 mutation
D. PMP22 gene duplication

Answer: GAA trinucleotide repeats

Neurodevelopmental Disabilities
Neuromuscular Medicine

1. A 17-year-old girl is brought in a wheelchair.

2. She has gradually progressive difficulty in walking, incoordination, and frequent falls.

3. Her symptoms started at 9 years old with clumsiness while walking.

4. Her difficulties with coordination later involved her arms and trunk.

5. She was born at term with normal developmental milestones.

6. The physical examination reveals severely ataxic gait.

7. The physical examination reveals nystagmus.

8. The physical examination reveals absent deep tendon reflexes.

9. The physical examination reveals loss of vibration and proprioception.

1. Her symptoms started at 9 years old with clumsiness while walking.

2. She later experienced difficulties with coordination.

3. The difficulties with coordination later involved her arms and trunk.

5. She had normal developmental milestones.


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

Context: A previously healthy 51-year-old man is brought to the emergency department because of confusion for 2 hours.

Context: On arrival, he is unconscious.

Context: His temperature is 37.1°C (98.8°F), pulse is 54/min, respirations are 8/min and irregular, and blood pressure is 198/106 mm Hg.

Context: The right pupil is dilated and fixed; the left pupil is round and reactive to light.

Context: A mannitol infusion is begun.

Choices:
A. Right-sided hemiplegia
B. Left-side facial nerve palsy
C. Bilateral spasticity
D. Multifocal myoclonus

Answer: Right-sided hemiplegia

1. A 51-year-old man is brought to the emergency department because of confusion for 2 hours.

2. His wife reports that he fell and hit his head while changing a ceiling light the previous evening.

6. His respirations are 8/min and irregular.

8. The right pupil is dilated and fixed.

9. The left pupil is round and reactive to light.

10. There is extension of the extremities to painful stimuli.

11. He is intubated and mechanically ventilated.

13. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe.

1. His wife reports that he fell and hit his head while changing a ceiling light the previous evening.

5. His respirations are 8/min and irregular.

7. The right pupil is dilated and fixed.

8. The left pupil is round and reactive to light.

9. There is extension of the extremities to painful stimuli.

10. He is intubated and mechanically ventilated.

12. A noncontrast CT scan of the brain shows herniation of the right medial temporal lobe.


Question: In addition to her current therapy, what additional steps should be taken during the management of this child's UTI?

Context: A 1-year-old female presents to the emergency department with 2 days of fever up to 103ºF.

Context: During the course of her work-up, a urine culture reveals gram negative rods and a urinary tract infection (UTI) is diagnosed.

Context: She is placed on ceftriaxone and quickly defervesces.

Context: coli, without any concerning resistance patterns and was susceptible to ceftriaxone.

Context: This is her first UTI and there is no family history of renal abnormalities or vesicourethral reflux.

Choices:
A. Prophylactic antibiotic therapy to prevent future UTIs
B. Voiding cystourethrogram
C. Renal bladder ultrasound
D. Repeat urine culture

Answer: Renal bladder ultrasound

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

3. A urine culture reveals gram negative rods.

7. Follow-up of the urine culture reveals the causal bacteria was E. coli.

8. There are no concerning resistance patterns.

9. The bacteria is susceptible to ceftriaxone.

11. There is no family history of renal abnormalities.

12. There is no family history of vesicourethral reflux.

1. Urine culture reveals gram negative rods

2. Urinary tract infection (UTI) is diagnosed

5. Causal bacteria in urine culture was E. coli

6. No concerning resistance patterns found in bacteria

7. Bacteria was susceptible to ceftriaxone

9. No family history of renal abnormalities

10. No family history of vesicourethral reflux


Question: Which of the following mechanisms was most likely involved in the development of this patient's symptoms?

Context: A 22-year-old woman presents to her primary care physician because she has been having severe pruritus on her left leg.

Context: She says the symptoms started 1 week ago after she went on a hiking trip with her friends.

Context: She wore shorts during the hike and felt as if something brushed her skin on the front of her leg just below the knee.

Context: She has no past medical history and no family history of autoimmune diseases.

Choices:
A. Activation of cell surface receptors by antibodies
B. Cross-linking of IgE antibodies
C. Cytotoxicity due to T-cells
D. Immune complex deposition

Answer: Cytotoxicity due to T-cells

1. A 22-year-old woman presents to her primary care physician.

2. She has been having severe pruritus on her left leg.

4. She went on a hiking trip with her friends.

6. She felt as if something brushed her skin on the front of her leg just below the knee.

8. She has no family history of autoimmune diseases.

9. On physical exam, she has red pruritic papules and vesicles on her left leg.

2. The symptoms started after a hiking trip with friends.

4. She felt something brush her skin on the front of her leg just below the knee.

6. She has no family history of autoimmune diseases.

7. On physical exam, she has red pruritic papules and vesicles on her left leg.


Question: Which of the following is the trinucleotide repeat linked to this patient’s most likely condition?

Context: An adopted 7-year-old boy is brought to a pediatrician with a history of progressive muscular weakness, intellectual impairment, and speech problems.

Context: The adoptive parents say that the patient was normal at birth, but as he grew older, his muscular weakness increased.

Context: Physical examination reveals the wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.

Context: Thenar and hypothenar eminences are also flattened.

Context: However, deep tendon reflexes are 2+ bilaterally.

Context: His face has an atypical appearance with thin cheeks and temporal wasting.

Context: When he was asked to make a tight fist and open his hands quickly, he could not open them immediately, and relaxation of the contracted muscles was very slow.

Choices:
A. CTG
B. CGG
C. GAA
D. CGT

Answer: CTG

1. An adopted 7-year-old boy is brought to a pediatrician.

2. The patient has a history of progressive muscular weakness, intellectual impairment, and speech problems.

3. The adoptive parents say the patient was normal at birth.

4. As the patient grew older, his muscular weakness increased.

5. Physical examination reveals wasting of muscles of the dorsal forearm and the anterior compartment of the lower legs.

6. Thenar and hypothenar eminences are flattened.

7. Deep tendon reflexes are 2+ bilaterally.

8. The patient's face has an atypical appearance with thin cheeks and temporal wasting.

9. When asked to make a tight fist and open his hands quickly, the patient could not open them immediately.

10. Relaxation of the contracted muscles was very slow.

11. The pediatrician suspects genetic muscular dystrophy.

1. The adoptive parents say the patient was normal at birth.

2. The patient's muscular weakness increased as he grew older.

3. Physical examination reveals wasting of muscles in the dorsal forearm and anterior compartment of the lower legs.

4. The thenar and hypothenar eminences are flattened.

5. Deep tendon reflexes are 2+ bilaterally.

6. The patient's face has an atypical appearance with thin cheeks and temporal wasting.

7. When asked to make a tight fist and open his hands quickly, the patient could not open them immediately, and relaxation of the contracted muscles was very slow.

8. The pediatrician suspects genetic muscular dystrophy.


Question: Which of the following is most consistent with this physical exam finding?

Context: She says that she has been experiencing some mild shortness of breath, but otherwise has no medical complaints.

Context: Her past medical history is significant for allergies and asthma as a child, but she is not currently taking any medications or supplements.

Context: She does not smoke and drinks about 2 glasses of wine per week as a social activity.

Choices:
A. Asthma recurrence
B. Atrial septal defect
C. Left bundle branch block
D. Pulmonary stenosis

Answer: Left bundle branch block

1. A 36-year-old woman presents to her primary care physician for her yearly physical exam.

2. She says that she has been experiencing some mild shortness of breath.

4. Her past medical history is significant for allergies and asthma as a child.

5. She is not currently taking any medications or supplements.

7. She drinks about 2 glasses of wine per week as a social activity.

8. On physical exam she is asked to take deep breaths during cardiac auscultation.

9. The physician notices that the splitting of S2 decreases during inspiration.

1. The patient has been experiencing mild shortness of breath.

2. The patient has no other medical complaints.

3. The patient had allergies and asthma as a child.

4. The patient is not currently taking any medications or supplements.

6. The patient drinks about 2 glasses of wine per week as a social activity.

7. During the physical exam, the patient is asked to take deep breaths during cardiac auscultation.

8. The physician notices that the splitting of S2 decreases during inspiration.


Question: Which of the following is appropriate initial management of this patient?

Context: A 47-year-old woman presents to the emergency department with calf pain and swelling that has persisted for the past 24 hours.

Context: She recently had an elective cholecystectomy performed 3 days ago that was complicated intraoperatively by bleeding requiring a transfusion of 1 unit of packed red blood cells.

Context: The patient is otherwise healthy, and her vitals are within normal limits.

Choices:
A. CT angiogram of the chest
B. Heparin
C. Inferior vena cava filter
D. Warfarin

Answer: Heparin

1. A 47-year-old woman presents to the emergency department.

2. She has calf pain and swelling that has persisted for the past 24 hours.

3. She recently had an elective cholecystectomy performed 3 days ago.

4. The cholecystectomy was complicated intraoperatively by bleeding.

5. The bleeding required a transfusion of 1 unit of packed red blood cells.

8. Physical exam is notable for an enlarged and tender right calf.

9. Ultrasound with doppler reveals non-compressible veins of the affected leg.

1. Elective cholecystectomy performed 3 days ago

2. Complicated intraoperatively by bleeding

3. Required transfusion of 1 unit of packed red blood cells

6. Physical exam notable for an enlarged and tender right calf

7. Ultrasound with doppler reveals non-compressible veins of the affected leg


Question: Which of the following options describe the most likely mechanism underlying the patient’s seizure?

Context: A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation with a headache and blurred vision.

Context: The vital signs are as follows: blood pressure, 170/95 mm Hg; heart rate, 88/min; respiratory rate, 15/min; and temperature, 36.6℃ (97.9℉).

Context: Meningeal signs are negative.

Context: The dipstick test shows 1+ proteinuria.

Context: While the blood is being drawn, the patient has a generalized tonic-clonic seizure.

Choices:
A. Increase in the extracellular sodium concentration
B. Failure of cerebral vasoregulation
C. Inhibition of brain GABA-signaling
D. Increased activation of NMDA receptors

Answer: Failure of cerebral vasoregulation

Maternal
Vascular Neurology
Maternal–Fetal Medicine

1. A 24-year-old primigravida is admitted to the hospital at 36 weeks gestation.

2. The patient has a headache and blurred vision.

3. The patient's blood pressure is 170/95 mm Hg.

5. The patient's respiratory rate is 15/min.

6. The patient's temperature is 36.6℃ (97.9℉).

7. The physical examination is significant for pitting edema of the lower extremity.

9. The ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate.

10. The dipstick test shows 1+ proteinuria.

11. The patient has a generalized tonic-clonic seizure while the blood is being drawn.

5. Physical examination significant for pitting edema of the lower extremity

7. Ophthalmoscopic exam shows vascular narrowing and a cotton-like fundal exudate

9. Patient has a generalized tonic-clonic seizure while blood is being drawn


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

Context: A 12-month-old girl is brought in by her mother to the pediatrician for the first time since her 6-month checkup.

Context: The mother states that her daughter had been doing fine, but the parents are now concerned that their daughter is still not able to stand up or speak.

Context: On exam, the patient has a temperature of 98.5°F (36.9°C), pulse is 96/min, respirations are 20/min, and blood pressure is 100/80 mmHg.

Context: A previous clinic note documents typical development at her 6-month visit and mentioned that the patient was sitting unsupported at that time.

Choices:
A. Language disorder
B. Rett syndrome
C. Fragile X syndrome
D. Trisomy 21

Answer: Rett syndrome

1. A 12-month-old girl is brought in by her mother to the pediatrician.

2. The mother states that her daughter had been doing fine.

3. The parents are now concerned that their daughter is still not able to stand up or speak.

4. The patient has a temperature of 98.5°F (36.9°C).

6. The patient's respirations are 20/min.

7. The patient's blood pressure is 100/80 mmHg.

8. The child appears to have difficulty supporting herself while sitting.

9. The patient has no other abnormal physical findings.

10. She plays by herself and is making babbling noises.

11. The patient does not respond to her own name.

12. She appears to have some purposeless motions.

13. A previous clinic note documents typical development at her 6-month visit.

14. The patient was sitting unsupported at her 6-month visit.

1. The mother states that her daughter had been doing fine.

2. The parents are concerned that their daughter is still not able to stand up or speak.

3. On exam, the patient has a temperature of 98.5°F (36.9°C).

5. The patient's respirations are 20/min.

6. The patient's blood pressure is 100/80 mmHg.

7. The child appears to have difficulty supporting herself while sitting.

8. The patient has no other abnormal physical findings.

9. She plays by herself and is making babbling noises but does not respond to her own name.

10. She appears to have some purposeless motions.

11. A previous clinic note documents typical development at her 6-month visit.

12. The patient was sitting unsupported at that time.


Question: In addition to adequate hydration, the patient is most likely to benefit from which of the following?

Context: A 55-year-old man comes to the emergency department because of cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.

Context: His temperature is 37.2°C (99.0°F), pulse is 107/min, and blood pressure is 145/80 mm Hg.

Choices:
A. Probenecid
B. Potassium citrate
C. High-protein diet
D. Hydrochlorothiazide

Answer: Potassium citrate

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

2. He has cramps and left-sided flank pain, nausea, and urinary frequency for 3 hours.

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

4. He drinks 2–3 alcoholic beverages daily.

8. Examination of the back shows left costovertebral angle tenderness.

9. An x-ray of the abdomen shows no abnormalities.

10. Abdominal ultrasound shows a 4-mm stone in the distal left ureter.

11. Abdominal ultrasound shows a scatter of small stones in the left renal pelvis.

12. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.

13. Pain medication and intravenous fluids are administered.

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

2. He drinks 2–3 alcoholic beverages daily.

6. Examination of the back shows left costovertebral angle tenderness.

7. An x-ray of the abdomen shows no abnormalities.

8. Abdominal ultrasound shows a 4-mm stone in the distal left ureter and a scatter of small stones in the left renal pelvis.

9. Urinalysis shows RBCs and needle-shaped crystals, but no WBCs.

10. Pain medication and intravenous fluids are administered.


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

Context: A 4-year-old boy is brought to the physician because of a 1-month history of generalized fatigue.

Context: During the past week, he has also had fever and severe leg pain that keeps him awake at night.

Context: His liver is palpated 4 cm below the right costal margin and the spleen is palpated 3 cm below the left costal margin.

Context: His hemoglobin concentration is 10.2 g/dL, leukocyte count is 64,500/mm3, and platelet count is 29,000/mm3.

Context: A bone marrow aspirate predominantly shows immature cells that stain positive for CD10, CD19, and TdT.

Choices:
A. Idiopathic thrombocytopenic purpura
B. Acute myeloid leukemia
C. Acute lymphoblastic leukemia
D. Hodgkin lymphoma

Answer: Acute lymphoblastic leukemia

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

2. He has a 1-month history of generalized fatigue.

3. During the past week, he has had fever and severe leg pain.

4. The leg pain keeps him awake at night.

5. Examination shows cervical and axillary lymphadenopathy.

6. His liver is palpated 4 cm below the right costal margin.

7. His spleen is palpated 3 cm below the left costal margin.

8. His hemoglobin concentration is 10.2 g/dL.

11. A bone marrow aspirate predominantly shows immature cells.

12. The immature cells stain positive for CD10.

13. The immature cells stain positive for CD19.

14. The immature cells stain positive for TdT.

1. He has had fever during the past week.

2. He has had severe leg pain that keeps him awake at night.

3. Examination shows cervical lymphadenopathy.

4. Examination shows axillary lymphadenopathy.

5. His liver is palpated 4 cm below the right costal margin.

6. His spleen is palpated 3 cm below the left costal margin.

7. His hemoglobin concentration is 10.2 g/dL.

10. A bone marrow aspirate predominantly shows immature cells.

11. The immature cells stain positive for CD10.

12. The immature cells stain positive for CD19.

13. The immature cells stain positive for TdT.


Question: Which of the following is the most likely consequence of this patient's condition?

Context: A 41-year-old man comes to the physician because of a 10-day history of generalized weakness.

Context: He has also had headaches and night sweats and is a known user of illicit intravenous drugs.

Context: His temperature is 39.1°C (102.4°F), pulse is 110/min, respirations are 17/min, and blood pressure is 127/78 mm Hg.

Context: Laboratory studies show a leukocyte count of 13,900/mm3 and an erythrocyte sedimentation rate of 58 mm/h.

Choices:
A. Hematuria
B. Rupture of nail-bed capillaries
C. Pulmonary embolism
D. Painful nodules on pads of the fingers

Answer: Pulmonary embolism

1. A 41-year-old man comes to the physician.

2. He has a 10-day history of generalized weakness.

3. He has also had headaches and night sweats.

4. He is a known user of illicit intravenous drugs.

9. There are several track marks on his forearms.

10. A holosystolic murmur that increases on inspiration is heard along the left sternal border.

11. Laboratory studies show a leukocyte count of 13,900/mm3.

12. Laboratory studies show an erythrocyte sedimentation rate of 58 mm/h.

3. He is a known user of illicit intravenous drugs.

8. There are several track marks on his forearms.

9. A holosystolic murmur is heard along the left sternal border.

10. The murmur increases on inspiration.


Question: Further examination and testing would most likely reveal which of the following findings in this patient?

Context: A 17-year-old girl presents to the emergency department with a painful rash on her head.

Context: She says that she started noticing a rash 2 weeks ago that has gotten worse over time.

Context: In addition, she says that she has been very thirsty over the same time period and often needs to urgently use the restroom during the day, which has been disrupting her ability to pay attention in school.

Context: Otherwise she says that she has some headaches, but attributes this to migraines that run in her family.

Context: She does not take any medications, doesn't smoke, and drinks socially with her friends.

Context: On physical exam, a disfiguring red scalp rash is observed and radiographs reveal lytic appearing skull lesions.

Choices:
A. Anti-nuclear antibodies on serology
B. Granules with tennis racket shape on electron microscopy
C. HLA-B27 gene variant on genetic testing
D. Noncaseating granulomas with multinucleated giant cells on histology

Answer: Granules with tennis racket shape on electron microscopy

2. Patient presents to the emergency department with a painful rash on her head.

3. Patient started noticing the rash 2 weeks ago.

5. Patient has been very thirsty over the same time period.

6. Patient often needs to urgently use the restroom during the day.

7. Patient's need to use the restroom has been disrupting her ability to pay attention in school.

8. Patient has some headaches, which she attributes to migraines that run in her family.

9. Patient does not take any medications.

11. Patient drinks socially with her friends.

12. On physical exam, a disfiguring red scalp rash is observed.

13. Radiographs reveal lytic appearing skull lesions.

1. The patient started noticing a rash 2 weeks ago.

3. The patient has been very thirsty over the same time period.

4. The patient often needs to urgently use the restroom during the day.

5. The restroom urgency has been disrupting her ability to pay attention in school.

7. The patient attributes the headaches to migraines that run in her family.

8. The patient does not take any medications.

10. The patient drinks socially with her friends.

11. On physical exam, a disfiguring red scalp rash is observed.

12. Radiographs reveal lytic appearing skull lesions.


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

Context: A 57-year-old man presents to the emergency department with a change in his mental status.

Context: His wife noticed he was particularly somnolent this evening which prompted her to bring him in.

Context: His temperature is 99.5°F (37.5°C), blood pressure is 97/58 mmHg, pulse is 40/min, respirations are 17/min, and oxygen saturation is 95% on room air.

Choices:
A. Calcium chloride
B. Dextrose
C. Glucagon
D. Transcutaneous pacing

Answer: Glucagon

1. A 57-year-old man presents to the emergency department.

2. His wife noticed he was particularly somnolent this evening.

3. His past medical history includes congestive heart failure, diabetes, and hypertension.

8. His oxygen saturation is 95% on room air.

9. A fingerstick blood glucose is notable for a value of 47 mg/dL.

1. The patient's wife noticed he was particularly somnolent this evening.

2. The patient has a past medical history of congestive heart failure, diabetes, and hypertension.

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

4. The patient's blood pressure is 97/58 mmHg.

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

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

8. A fingerstick blood glucose is notable for a value of 47 mg/dL.


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

Context: He's "trying to get in better shape.” The patient has no complaints except for occasional headaches when he is stressed about exams.

Context: His testes are less than 20 mL in volume, and his phallus measures less than 8 cm.

Context: Initial labs show testosterone levels of 95 ng/dL and a low follicle stimulating hormone/luteinizing hormone ratio.

Choices:
A. Adrenocorticotrophic hormone stimulation test
B. Semen analysis
C. Spectral karyotype
D. Thyroid-stimulating hormone and prolactin levels

Answer: Thyroid-stimulating hormone and prolactin levels

1. A 16-year-old boy comes to his primary care clinic for a sports physical.

2. He states that he wants to try out for his high school’s football team this year.

3. He's "trying to get in better shape.”

4. The patient has no complaints except for occasional headaches when he is stressed about exams.

5. The patient also mentions that he is embarrassed of his “small penis” and asks if there is something he can take for that.

6. The patient’s temperature is 98°F (36.7°C).

7. The patient’s blood pressure is 118/76 mmHg.

9. On physical examination, the patient is obese and has no visible facial hair.

10. His testes are less than 20 mL in volume.

11. His phallus measures less than 8 cm.

12. Initial labs show testosterone levels of 95 ng/dL.

13. Initial labs show a low follicle stimulating hormone/luteinizing hormone ratio.

1. The patient wants to try out for his high school’s football team this year.

2. He is "trying to get in better shape.”

3. The patient has occasional headaches when stressed about exams.

4. The patient is embarrassed about his “small penis” and asks if there is something he can take for that.

5. The patient’s temperature is 98°F (36.7°C), blood pressure is 118/76 mmHg, and pulse is 79/min.

6. On physical examination, the patient is obese and has no visible facial hair.

7. His testes are less than 20 mL in volume.

9. Initial labs show testosterone levels of 95 ng/dL.

10. The patient has a low follicle stimulating hormone/luteinizing hormone ratio.


Question: Which of the following statements regarding this patient’s myocardial tissue is true?

Context: A 72-year-old man presents to the hospital with retrosternal chest pain and shortness of breath.

Choices:
A. This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.
B. The changes shown on this slide are a result of iron overload.
C. The slide shows cardiac steatosis.
D. The microscopic image reveals cardiac tissue hypertrophy.

Answer: This slide shows changes in the myocardial tissue that result from lipid peroxidation during the patient's lifetime.

2. Patient presents with retrosternal chest pain and shortness of breath.

3. Pain started 5 hours prior to arrival.

4. Pain has not changed after sublingual nitroglycerin intake.

5. Patient has a history of long-standing persistent atrial fibrillation.

6. Patient was not taking anticoagulants at the time of presentation.

7. Patient had been diagnosed with iron-deficiency anemia 3 months before admission.

8. Patient is taking 120 mg of elemental iron daily.

9. Patient has no history of ischemic heart disease.

10. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.

11. Patient is managed with percutaneous coronary intervention (PCI).

12. Six hours after the PCI, the patient develops cardiogenic shock.

13. 8 hours after presentation, patient dies despite intensive care management.

14. Autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.

15. Microscopic image depicts macroscopically intact myocardium.

1. The pain started 5 hours prior to arrival and has not changed after sublingual nitroglycerin intake.

2. The patient has a history of long-standing persistent atrial fibrillation but had not been taking anticoagulants at the time of presentation.

3. He had also been diagnosed with iron-deficiency anemia 3 months before admission and is taking 120 mg of elemental iron daily.

4. He has no history of ischemic heart disease.

5. Clinical investigation confirms inferior ST-elevation myocardial infarction with occlusion of the right coronary artery.

6. The patient is managed with percutaneous coronary intervention (PCI).

7. Six hours after the PCI, the patient develops cardiogenic shock; 8 hours after presentation, he dies, despite intensive care management.

8. The autopsy reveals widespread inferior-posterior myocardial infarction and thrombotic occlusion of the left circumflex artery.

9. The microscopic image depicts a macroscopically intact myocardium.


Question: Which of the following forms of inheritance is associated with the most likely cause of this patient's disorder?

Context: A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube in order to allow for better ventilator support of his breathing.

Context: Since then, his weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.

Context: Family history reveals that his grandfather was affected by a degenerative disorder at age 50, and his father had the same degenerative disorder at age 30.

Context: Examination is significant for tongue fasciculations and absent deep tendon reflexes.

Choices:
A. Autosomal dominant on chromosome 19
B. Autosomal recessive on chromosome 5
C. Autosomal recessive on chromosome 9
D. X-linked dominant

Answer: Autosomal recessive on chromosome 5

Pediatric Pulmonology
Pediatric Critical Care Medicine

1. A 3-year-old boy is brought in by his parents for placement of a tracheostomy tube.

2. At birth, he was flaccid with a poor sucking reflex.

3. His weakness has progressively worsened such that he is unable to sit, eat, or breathe independently.

4. Family history reveals his grandfather was affected by a degenerative disorder at age 50.

5. His father had the same degenerative disorder at age 30.

6. Examination is significant for tongue fasciculations.

7. Examination is significant for absent deep tendon reflexes.

1. At birth, he was flaccid with a poor sucking reflex.

2. His weakness has progressively worsened.

3. He is unable to sit, eat, or breathe independently.

4. Family history reveals that his grandfather was affected by a degenerative disorder at age 50.


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

Context: A 73-year-old man is brought to the emergency department 30 minutes after the sudden onset of right-sided body weakness.

Context: He has type 2 diabetes mellitus and has smoked 1 pack of cigarettes daily for 45 years.

Context: The patient speaks fluently, but he answers questions with nonsensical phrases and cannot repeat single words.

Choices:
A. Conduction aphasia
B. Global aphasia
C. Wernicke aphasia
D. Transcortical sensory aphasia

Answer: Wernicke aphasia

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

3. The symptoms are right-sided body weakness.

4. His wife reports that he does not seem to understand simple questions.

6. He has smoked 1 pack of cigarettes daily for 45 years.

8. He answers questions with nonsensical phrases.

1. The patient's wife reports that he does not seem to understand simple questions.

3. He has smoked 1 pack of cigarettes daily for 45 years.

5. He answers questions with nonsensical phrases.


Question: This patient's skin finding is most likely associated with which of the following conditions?

Context: She feels well.

Context: She is 155 cm (5 ft 1 in) tall and weighs 79 kg (174 lb); BMI is 33 kg/m2.

Choices:
A. Niacin deficiency
B. Primary adrenal insufficiency
C. Polycystic ovarian syndrome
D. Hashimoto thyroiditis

Answer: Polycystic ovarian syndrome

1. A 23-year-old woman comes to physician for an annual health maintenance examination.

6. Examination shows a skin rash over both axillae.

7. A photograph of her left axilla is shown.

5. Examination shows a skin rash over both axillae.

6. A photograph of her left axilla is shown.


Question: Damage to which of the following structures is most likely to be responsible for her language deficits?

Context: A 72-year-old female is brought in by ambulance after being found down in her home.

Choices:
A. Arcuate fasciculus
B. Inferior frontal gyrus
C. Inferior frontal gyrus + superior temporal gyrus
D. Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus

Answer: Arcuate fasciculus + Inferior frontal gyrus + superior temporal gyrus

1. A 72-year-old female is brought in by ambulance.

2. Her daughter discovered her after returning from work and does not know how long she has been down.

3. Physical exam reveals right sided paralysis with a positive babinski sign.

4. She is also found to produce strained stuttering speech with no perceivable meaning.

5. She is unable to follow any instructions and cannot repeat speech.

6. An MRI is obtained showing a left MCA infarct.

1. Her daughter discovered her after returning from work.

2. Her daughter does not know how long she has been down.

3. Physical exam reveals right sided paralysis.

4. Physical exam reveals a positive babinski sign.

5. She is found to produce strained stuttering speech.

6. The speech has no perceivable meaning.

7. She is unable to follow any instructions.


Question: At steady state, which of the following sets of findings is most likely in this patient?

Context: A 66-year-old male with a history of diabetes and knee osteoarthritis presents to his primary care provider in July complaining of headaches and blurry vision.

Context: He reports a 6-month history of occasional dull diffuse headaches and blurry vision.

Context: He notes that the episodes have increased in severity since the weather got warmer and that he occasionally feels extremely itchy when he spends time outdoors.

Context: The patient lives in southern Arizona.

Context: Moreover, he has felt chronically fatigued and has lost 10 pounds without dieting or changing his appetite.

Context: He currently takes metformin and his most recent hemoglobin A1c was 6.5%.

Context: Multiple laboratory tests are pending.

Choices:
A. Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2
B. Normal plasma volume, increased RBC mass, increased EPO, normal SaO2
C. Decreased plasma volume, normal RBC mass, normal EPO, normal SaO2
D. Increased plasma volume, decreased RBC mass, decreased EPO, normal SaO2

Answer: Increased plasma volume, increased RBC mass, decreased EPO, normal SaO2

1. A 66-year-old male presents to his primary care provider in July.

2. He has a history of diabetes and knee osteoarthritis.

3. He complains of headaches and blurry vision.

4. He has a 6-month history of occasional dull diffuse headaches and blurry vision.

5. The episodes have increased in severity since the weather got warmer.

6. He occasionally feels extremely itchy when he spends time outdoors.

9. He has lost 10 pounds without dieting or changing his appetite.

11. His most recent hemoglobin A1c was 6.5%.

12. Physical examination reveals multiple bruises on the bilateral upper and lower extremities and hepatosplenomegaly.

13. Fundoscopic examination demonstrates enlarged retinal veins.

14. Multiple laboratory tests are pending.

1. The patient reports a 6-month history of occasional dull diffuse headaches and blurry vision.

2. The episodes have increased in severity since the weather got warmer.

3. He occasionally feels extremely itchy when he spends time outdoors.

4. The patient lives in southern Arizona.

6. He has lost 10 pounds without dieting or changing his appetite.

8. His most recent hemoglobin A1c was 6.5%.

9. Physical examination reveals multiple bruises on the bilateral upper and lower extremities.

10. Physical examination reveals hepatosplenomegaly.

11. Fundoscopic examination demonstrates enlarged retinal veins.

12. Multiple laboratory tests are pending.


Question: This patient's behavior is characteristic of a condition that is most typically associated with which of the following?

Context: While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery because she does not trust doctors.

Choices:
A. Repeated performance of certain routines
B. Substance use disorder
C. Fear of social situations
D. Self-injurious behavior

Answer: Self-injurious behavior

1. A 25-year-old woman is brought to the emergency department for the evaluation of severe abdominal pain for the last hour.

2. Abdominal ultrasound shows a non-compressible and enlarged appendix.

3. The patient is diagnosed with acute appendicitis.

4. While obtaining informed consent from the patient for appendectomy, the patient reports that she does not want to undergo surgery.

5. The patient states that all doctors are “bad”.

6. The patient states that all doctors think about is money.

7. The patient states that nurses are “angels”.

8. The patient states that nurses should take care of her instead of the “arrogant” doctors.

1. Abdominal ultrasound shows a non-compressible and enlarged appendix.

2. The patient is diagnosed with acute appendicitis.

3. The patient reports that she does not want to undergo surgery because she does not trust doctors.

4. She states that all doctors are “bad” and all they think about is money.

5. She adds that she thinks that nurses are “angels” and that they should take care of her instead of the “arrogant” doctors.


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

Context: A 20-year-old woman presents with persistent sadness for the last 2 months.

Context: She says that she is always feeling tired and nothing seems to cheer her up.

Context: Although previously a top student at her college, she did not register for classes this term, because she does not feel like going to school anymore.

Context: She says her friends complain that she does not want to ‘hang out’ with them anymore.

Context: She is sleeping more than usual and often does not want to leave the bed in the morning.

Context: The patient denies any suicidal ideation or preoccupation with death.

Context: She currently takes a daily multivitamin.

Context: The vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).

Context: Her body mass index (BMI) is 17.5 kg/m2.

Context: On physical examination, the patient is pale.

Choices:
A. Mirtazapine
B. Lorazepam
C. Bupropion
D. Amitriptyline

Answer: Mirtazapine

2. Patient has persistent sadness for the last 2 months.

3. Patient is always feeling tired and nothing seems to cheer her up.

4. Patient was previously a top student at her college.

5. Patient did not register for classes this term.

6. Patient's friends complain that she does not want to 'hang out' with them anymore.

8. Patient often does not want to leave the bed in the morning.

9. Patient denies any suicidal ideation or preoccupation with death.

10. Patient's past medical history is unremarkable.

11. Patient currently takes a daily multivitamin.

12. Patient's vital signs include pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, and temperature 36.9°C (98.5°F).

13. Patient's body mass index (BMI) is 17.5 kg/m2.

14. On physical examination, patient is pale.

15. Mucous membranes and oral cavity are dry with poor dentition.

16. Multiple calluses are present on the knuckles of her left hand.

1. The patient reports feeling constantly tired and unable to find joy in anything.

2. She was a top student at her college but did not register for classes this term due to lack of motivation.

3. Her friends have noticed that she no longer wants to spend time with them.

4. She is sleeping more than usual and struggles to get out of bed in the morning.

5. The patient denies having any thoughts of suicide or preoccupation with death.

6. Her past medical history is unremarkable.

8. Vital signs: pulse 64/min, respiratory rate 12/min, blood pressure 110/70 mm Hg, temperature 36.9°C (98.5°F).

10. On physical examination, the patient appears pale.

11. Her mucous membranes and oral cavity are dry with poor dentition.

12. Multiple calluses are present on the knuckles of her left hand.


Question: Which of the following was the most likely vector that transmitted the disease to this for patient?

Context: A 31-year-old man presents to the clinic with complaints of sudden onset of fever, headache, chills, and a painful “bump” in his right groin.

Context: His physical exam is notable for an enlarged lymph node in the inguinal region that is extremely tender to palpation.

Context: The patient is promptly treated with antibiotics, and his case is reported to the Centers for Disease Control and Prevention.

Choices:
A. Armadillo
B. Flea
C. Rat
D. Tick

Answer: Flea

1. A 31-year-old man presents to the clinic.

2. He has sudden onset of fever, headache, chills, and a painful “bump” in his right groin.

3. He recently spent three months working as a park ranger in New Mexico.

4. His physical exam is notable for an enlarged lymph node in the inguinal region.

5. The lymph node is extremely tender to palpation.

6. The patient is promptly treated with antibiotics.

7. His case is reported to the Centers for Disease Control and Prevention.

1. He recently spent three months working as a park ranger in New Mexico.

2. His physical exam is notable for an enlarged lymph node in the inguinal region.

3. The enlarged lymph node is extremely tender to palpation.

4. The patient is promptly treated with antibiotics.

5. His case is reported to the Centers for Disease Control and Prevention.


Question: Which of the devices has the best precision?

Context: As the only full-time inpatient endocrinologist at your hospital, you have been tasked with deciding which blood glucose measuring device to use on the wards.

Context: A medical device representative presents you with the data in Image A.

Context: All readings were performed on the same individual whose blood glucose was known to be 125 mg/dL at the time.

Choices:
A. Device B
B. Device C
C. Device D
D. Not enough information provided

Answer: Device D

Endocrinology, Diabetes, and Metabolism
Chemical Pathology
Clinical Chemistry

1. The speaker is an inpatient endocrinologist.

2. The speaker works full-time at a hospital.

3. The speaker has been tasked with deciding which blood glucose measuring device to use on the wards.

4. A medical device representative presented the speaker with data in Image A.

5. All readings in Image A were performed on the same individual.

6. The individual's blood glucose was known to be 125 mg/dL at the time of the readings.

1. A medical device representative presents data in Image A.

2. All readings were performed on the same individual.

3. The individual's blood glucose was known to be 125 mg/dL at the time.


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

Context: A 21-year-old male comes to the physician’s office with complaints of fatigue.

Context: The patient is a college intramural athlete and has noticed that during hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.

Context: On exam, the patient has no acute symptoms and appears to be sitting comfortably with a completely normal exam.

Choices:
A. Glucose-6-phosphatase
B. Debranching enzyme
C. Glycogen phosphorylase
D. Acid maltase

Answer: Glycogen phosphorylase

Endocrinology, Diabetes, and Metabolism
General Pediatrics
Metabolic Genetics

1. A 21-year-old male comes to the physician's office with complaints of fatigue.

2. The patient is a college intramural athlete.

3. During hard workouts with his team, he gets severe muscle pain and weakness to the point where he has to stop and rest.

4. Usually he is able to recover and the cramps subside after rest.

5. After strenuous workouts he has also noticed that his urine is dark.

6. On exam, the patient has no acute symptoms.

7. The patient appears to be sitting comfortably with a completely normal exam.

8. The patient does not have any tenderness to palpation of his muscles.

1. The patient is a college intramural athlete.

2. During hard workouts with his team, he gets severe muscle pain and weakness.

3. He has to stop and rest during hard workouts.

4. He is able to recover and the cramps subside after rest.

5. After strenuous workouts, his urine is dark.


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

Context: A 78-year-old man comes to the physician because of a 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and a feeling of fullness in his head.

Context: He does not smoke cigarettes.

Choices:
A. Pancoast tumor
B. Constrictive pericarditis
C. Descending aortic aneurysm
D. Mediastinal lymphoma

Answer: Mediastinal lymphoma

2. Patient has 3-week history of dyspnea, chest pain, dry cough, painful swallowing, and feeling of fullness in head.

3. Symptoms initially mild but have progressively worsened.

4. Patient has history of gastroesophageal reflux disease treated with esomeprazole.

8. Examination shows swelling and redness of face and neck.

9. Distention of superficial veins of neck and upper thorax.

10. Plain radiographs of chest show widened mediastinum and unremarkable lung fields.

1. The symptoms were initially mild but have progressively worsened.

2. He has a history of gastroesophageal reflux disease treated with esomeprazole.

4. His pulse is 99/min and blood pressure is 95/66 mm Hg.

5. Examination shows swelling and redness of the face and neck.

6. There is distention of the superficial veins of his neck and upper thorax.

7. Plain radiographs of the chest show a widened mediastinum and unremarkable lung fields.


Question: A drug with which of the following mechanisms of action is most appropriate for this patient?

Context: A 52-year-old man is brought to the emergency department 30 minutes after his farmhand found him on the ground sweating profusely.

Context: On arrival, he is lethargic and unable to provide any history.

Context: His temperature is 37.5°C (99.5°F), pulse is 42/min, and blood pressure is 95/60 mm Hg.

Context: The pupils are constricted.

Choices:
A. Non-selective α adrenergic receptor antagonism
B. β2 adrenergic receptor agonism
C. Muscarinic acetylcholine receptor antagonism
D. Nicotinic acetylcholine receptor agonism

Answer: Muscarinic acetylcholine receptor antagonism

1. A 52-year-old man was brought to the emergency department.

2. His farmhand found him on the ground sweating profusely 30 minutes prior.

3. He is lethargic and unable to provide any history.

7. Physical examination shows diaphoresis and excessive salivation.

9. There is scattered expiratory wheezing throughout both lung fields.

10. His clothes are soaked with vomit, urine, and feces.

1. On arrival, the patient is lethargic and unable to provide any history.

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

4. The patient's blood pressure is 95/60 mm Hg.

5. Physical examination shows diaphoresis and excessive salivation.

6. The patient's pupils are constricted.

7. There is scattered expiratory wheezing throughout both lung fields.

8. The patient's clothes are soaked with vomit, urine, and feces.


Question: What is the best next step in management?

Context: A 40-year-old woman is admitted to the hospital about four hours after her husband discovered that she ingested a bottle of acetaminophen in an attempted suicide.

Context: Physical exam is unremarkable.

Choices:
A. Administer NAC
B. Cancel the NAC order
C. Involve the patient's husband to guide medical care
D. Force the patient to accept NAC

Answer: Involve the patient's husband to guide medical care

1. A 40-year-old woman is admitted to the hospital.

2. Her husband discovered that she ingested a bottle of acetaminophen four hours prior.

3. The patient denies any symptoms at this time.

4. Blood pressure is 115/80 mmHg and pulse is 85/min.

6. AST and ALT levels are approximately 2500 U/L.

9. The patient refuses N-acetyl-cysteine (NAC) treatment.

1. The patient denies any symptoms at this time.

2. Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min.

4. AST and ALT levels are approximately 2500 U/L.

5. APAP level is 160 mcg/mL, and INR is 1.7.

6. The patient refuses N-acetyl-cysteine (NAC) treatment.


Question: What is the pathophysiology of this patient’s condition?

Context: An 11-month-old baby boy is brought to the emergency room by his parents for vomiting.

Context: However, his condition worsened today when he began coughing and struggling to breathe.

Context: During one of his coughing spells he threw up his milk as well.

Choices:
A. Generation of reactive oxygen species
B. Production of IgA proteases
C. Toxin that inactivates Gi protein
D. Toxin that permanently activates Gs protein

Answer: Toxin that inactivates Gi protein

1. An 11-month-old baby boy is brought to the emergency room by his parents.

2. His mom reports he has had a cold for the past week with a runny nose and low-grade fevers.

3. His condition worsened today when he began coughing and struggling to breathe.

4. During one of his coughing spells he threw up his milk.

5. The parents deny any sick contacts, changes in diet, or bowel changes.

6. The parents endorse fatigue and decreased appetite.

7. A physical examination demonstrates a healthy-looking baby with an intense cough.

8. A physical examination demonstrates a healthy-looking baby with significant inspiratory stridor.

1. His mom reports that he has had a cold for the past week with a runny nose and low-grade fevers.

2. His condition worsened today when he began coughing and struggling to breathe.

3. During one of his coughing spells he threw up his milk.

4. The parents deny any sick contacts, changes in diet, or bowel changes but endorse fatigue and decreased appetite.

5. A physical examination demonstrates a healthy-looking baby with an intense cough and significant inspiratory stridor.


Question: Which of the following underlying conditions most likely predisposed this patient to develop this reaction?

Context: A 56-year-old male undergoes a pancreaticoduodenectomy for resection of a tumor of the head of the pancreas.

Context: His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood that were effectively treated with antibiotics.

Context: Before today, he has not had any prior surgeries or required a blood transfusion.

Context: His vital signs show a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.

Choices:
A. Severe combined immunodeficiency disorder
B. Bruton's agammaglobulilnemia
C. Wiskott-Aldrich syndrome
D. Selective IgA deficiency

Answer: Selective IgA deficiency

2. Patient underwent pancreaticoduodenectomy.

3. Reason for surgery was resection of a tumor of the head of the pancreas.

4. Patient's medical history includes minor respiratory and gastrointestinal infections since childhood.

5. Patient has not had any prior surgeries or required a blood transfusion.

6. Hemoglobin measured in post anesthesia care unit was 5.2 g/dL.

7. 2 units of packed red blood cells were ordered for transfusion.

8. Minutes after transfusion was initiated, patient reported severe itching, nausea, and shortness of breath.

9. Patient's vital signs showed a drop in blood pressure from 138/88 to 92/47 and an increase in heart rate from 94 to 118.

10. Transfusion was stopped immediately by the patient's nurse.

1. His medical history is otherwise insignificant except for a series of minor respiratory and gastrointestinal infections since childhood.

2. The infections were effectively treated with antibiotics.

3. Before today, he has not had any prior surgeries.

4. Before today, he has not required a blood transfusion.

5. In the post anesthesia care unit, his hemoglobin is measured and found to be 5.2 g/dL.

6. A transfusion of 2 units of packed red blood cells is ordered.

7. Minutes after the transfusion is initiated, the patient reports severe itching, nausea, and shortness of breath.

8. His vital signs show a drop in blood pressure from 138/88 to 92/47.

9. His vital signs show an increase in heart rate from 94 to 118.

10. The patient's nurse stops the transfusion immediately.


Question: Which of the inheritance patterns can be attributed to the girl’s condition?

Context: The sclera of both eyes are blue.

Choices:
A. Pleiotropy
B. Anticipation
C. Locus heterogeneity
D. De novo mutation

Answer: Locus heterogeneity

1. A 5-year-old girl is brought to the emergency department after sustaining an atraumatic tibial fracture while playing with her friends.

2. This patient has a history of fractures in her upper and lower extremities.

3. Children's services have investigated the family several times in the past and found no abuse.

4. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.

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

6. The mother has a brother with a similar history that is still living.

7. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).

8. Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.

10. Additionally, her teeth are brown and distorted.

11. Her leg is swollen, erythematous, and tender to palpation.

12. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.

13. The physician suspects this is a genetic condition.

1. The patient has a history of fractures in her upper and lower extremities.

2. Children's services have investigated the family several times in the past and found no abuse.

3. She was born at 39 weeks gestation via spontaneous vaginal delivery which resulted in several mild fractures.

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

5. The mother has a brother with a similar history that is still living.

6. Her vital signs show a heart rate of 90/min, respiratory rate of 22/min, blood pressure of 110/65 mm Hg, and temperature of 37.0°C (98.6°F).

7. Physical exam reveals a regular heart rate, and her lungs are clear to auscultation bilaterally.

9. Additionally, her teeth are brown and distorted.

10. Her leg is swollen, erythematous, and tender to palpation.

11. An X-ray reveals a tibia fracture, while multiple fractures at various stages of healing are also seen on her arms.

12. The physician suspects this is a genetic condition.


Question: Which of the following is the most likely mechanism of action for the medication that was started in this patient?

Context: A 72-year-old woman presents to her primary care physician because she is coughing pink sputum and has difficulty breathing.

Context: She says that she was feeling pretty good until she traveled to her grandson's wedding last week.

Context: Physical exam reveals swollen ankles, basilar crackles bilaterally, and a murmur best heard in the left lateral decubitus position.

Context: She is already taking several medications for this condition; however, given the recent worsening of symptoms she is started on an additional medication.

Choices:
A. Competitive inhibition of hormonal signaling
B. Decrease in adenylyl cyclase activity
C. Inhibition of Na-Cl symporter
D. Inhibition of Na-K-Cl cotransporter

Answer: Inhibition of Na-K-Cl cotransporter

1. A 72-year-old woman presents to her primary care physician.

2. She is coughing pink sputum and has difficulty breathing.

3. She was feeling pretty good until she traveled to her grandson's wedding last week.

4. Since then she has had increasing difficulty sleeping and walking due to her shortness of breath.

5. Physical exam reveals swollen ankles.

6. Physical exam reveals basilar crackles bilaterally.

7. Physical exam reveals a murmur best heard in the left lateral decubitus position.

8. She is already taking several medications for this condition.

9. Given the recent worsening of symptoms she is started on an additional medication.

1. The patient was feeling pretty good until she traveled to her grandson's wedding last week.

2. Since then, she has had increasing difficulty sleeping and walking due to her shortness of breath.

3. Physical exam reveals swollen ankles.

4. Physical exam reveals basilar crackles bilaterally.

5. Physical exam reveals a murmur best heard in the left lateral decubitus position.

6. The patient is already taking several medications for this condition.

7. Given the recent worsening of symptoms, she is started on an additional medication.


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

Context: She reports that the pain is constant, 10/10, and is diffusely spread across her stomach.

Context: She reports nausea and 1 episode of vomiting 1 hour ago, painless bloody urine, and paresthesias in her hands bilaterally.

Context: Her temperature is 98.6°F (37°C), blood pressure is 148/98 mmHg, pulse is 103/min, respirations are 18/min, and oxygen saturation is 99% on room air.

Choices:
A. Implantation of the embryo outside of the uterus
B. Inflammation of the appendix
C. Mutation of the porphobilinogen deaminase enzyme
D. Obstruction of the cystic duct and subsequent inflammation of the gallbladder

Answer: Mutation of the porphobilinogen deaminase enzyme

1. A 37-year-old woman is brought to the emergency department for acute abdominal pain for the past 2 hours.

2. The pain is constant, 10/10, and is diffusely spread across her stomach.

3. She reports nausea and 1 episode of vomiting 1 hour ago.

4. She reports painless bloody urine and paresthesias in her hands bilaterally.

5. The patient claims similar episodes in the past following the use of alcohol, though with milder pain.

6. Her past medical history is significant for pelvic inflammatory disease that was adequately treated 5 years ago.

7. She is currently sexually active with her husband without contraceptive use.

12. Her oxygen saturation is 99% on room air.

13. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness.

14. A physical examination demonstrates decreased sensation of the hands bilaterally.

1. The patient reports constant, 10/10 pain diffusely spread across her stomach.

2. The patient reports nausea and 1 episode of vomiting 1 hour ago.

3. The patient reports painless bloody urine and paresthesias in her hands bilaterally.

4. The patient claims similar episodes in the past following the use of alcohol, though with milder pain.

5. The patient's past medical history includes adequately treated pelvic inflammatory disease 5 years ago.

6. The patient is currently sexually active with her husband without contraceptive use.

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

8. The patient's blood pressure is 148/98 mmHg.

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

11. The patient's oxygen saturation is 99% on room air.

12. A physical examination demonstrates a patient in acute distress with diffuse abdominal tenderness and decreased sensation of the hands bilaterally.


Question: Which of the following represents the overall specificity of this novel test?

Context: Of the 300 patients enrolled, half are diagnosed with RA.

Choices:
A. 105 / (105 + 25)
B. 125 / (125 + 105)
C. 105 / (105 + 45)
D. 125 / (125 + 25)

Answer: 105 / (105 + 45)

Rheumatology
Clinical Biochemical Genetics

1. A medical research study is being conducted to evaluate the specificity of a novel blood test for rheumatoid arthritis.

2. 300 patients are enrolled in the study.

3. Half of the patients enrolled are diagnosed with RA.

4. The remaining patients are age-matched controls.

5. 125 patients with RA are found positive for the novel blood test.

6. 45 patients in the control group are found positive for the novel blood test.

1. 300 patients are enrolled in the study.

2. Half of the patients are diagnosed with RA.

3. The remaining patients are age-matched controls.

4. In the subgroup of patients with RA, 125 are found positive for the novel blood test.

5. In the control group, 45 are found positive.