Context: A 74-year-old man comes to the physician for a 6-month history of progressively worsening fatigue and shortness of breath on exertion. He immigrated to the United States 35 years ago from India. His pulse is 89/min and blood pressure is 145/60 mm Hg. Crackles are heard at the lung bases. Cardiac examination shows a grade 3/6 early diastolic murmur loudest at the third left intercostal space. Further evaluation of this patient is most likely to show which of the following?

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

Answer: Water hammer pulse


Context: An 11-year-old boy is brought to the physician by his mother because of a pruritic generalized rash for 2 days. He returned from a 3-day outdoor summer camp 1 week ago. During his time there, one child was sent home after being diagnosed with measles. The patient was diagnosed with a seizure disorder 6 weeks ago and he has asthma. Current medications include carbamazepine and an albuterol inhaler. His immunization records are unavailable. His temperature is 38.4°C (101.1°F), pulse is 88/min, and blood pressure is 102/60 mm Hg. Examination shows facial edema and a diffuse rash over the face, trunk, and extremities. There is cervical and inguinal lymphadenopathy. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

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

Answer: Discontinue carbamazepine


Context: A 68-year-old man with type 2 diabetes mellitus comes to the physician because of a 5-month history of episodic palpitations, dizziness, and fatigue. His pulse is 134/min and irregularly irregular, and his blood pressure is 165/92 mm Hg. An ECG shows a narrow complex tachycardia with absent P waves. He is prescribed a drug that decreases the long-term risk of thromboembolic complications by inhibiting the extrinsic pathway of the coagulation cascade. The expected beneficial effect of this drug is most likely due to which of the following actions?

Question: The expected beneficial effect of this drug is most likely due to which of the following actions?

Answer: Inhibit the reduction of vitamin K


Context: A previously healthy 26-year-old man is brought to the emergency department 30 minutes after collapsing during soccer practice. The patient appears well. His pulse is 73/min and blood pressure is 125/78 mm Hg. Cardiac examination is shown. Rapid squatting decreases the intensity of the patient's auscultation finding. Which of the following is the most likely cause of this patient's condition?

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

Answer: Asymmetric hypertrophy of the septum


Context: A 43-year-old man comes to the physician because of anxiety, difficulty focusing on tasks, and a 4.6-kg (10-lb) weight loss over the past 4 weeks. He is diaphoretic. His pulse is 100/min, respirations are 18/min, and blood pressure is 150/78 mm Hg. Physical examination shows warm, moist skin, goiter, and a resting tremor of both hands. Laboratory studies show a thyroxine (T4) concentration of 30 μg/dL and a thyroid-stimulating hormone concentration of 0.1 μU/mL. The patient is started on methimazole and atenolol. The latter agent predominantly affects which of the following?

Question: The latter agent predominantly affects which of the following?

Answer: Atrioventricular node activity


Context: A 45-year-old man comes to the emergency department with fever, nonproductive cough, and difficulty breathing. Three years ago, he underwent lung transplantation. A CT scan of the chest shows diffuse bilateral ground-glass opacities. Pathologic examination of a transbronchial lung biopsy specimen shows several large cells containing intranuclear inclusions with a clear halo. Treatment with ganciclovir fails to improve his symptoms. He is subsequently treated successfully with another medication. This drug does not require activation by viral kinases and also has known in-vitro activity against HIV and HBV. The patient was most likely treated with which of the following drugs?

Question: The patient was most likely treated with which of the following drugs?

Answer: Foscarnet


Context: A 42-year-old woman comes to the physician because of a 2-week history of joint pain and fatigue. She has a history of multiple unprovoked deep vein thromboses. Physical examination shows small bilateral knee effusions and erythematous raised patches with scaling and follicular plugging over the ears and scalp. Oral examination shows several small ulcers. Laboratory evaluation of this patient is most likely to show which of the following?

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

Answer: Positive rapid plasma reagin test


Context: A 53-year-old woman comes to the physician because of increasing shortness of breath on exertion for 5 months. She reports that she can not climb more than 2 flights of stairs and she is no longer able to run her errands as usual. One year ago, she was diagnosed with triple-negative breast cancer. She underwent a right-sided modified radical mastectomy and adjuvant chemotherapy. Cardiac examination shows a laterally displaced point of maximal impulse. Coarse inspiratory crackles are heard in both lower lung fields. Echocardiography shows a left ventricular ejection fraction of 30%. The physician informs the patient that her symptoms are most likely due to an adverse effect of her chemotherapy. The drug most likely responsible for the patient's current symptoms belongs to which of the following groups of agents?

Question: The drug most likely responsible for the patient's current symptoms belongs to which of the following groups of agents?

Answer:
Anthracyclines
"


Context: A 79-year-old male presents to your office for his annual flu shot. On physical exam you note several linear bruises on his back. Upon further questioning he denies abuse from his daughter and son-in-law, who live in the same house. The patient states he does not want this information shared with anyone. What is the most appropriate next step, paired with its justification?

Question: What is the most appropriate next step, paired with its justification?

Answer: Breach patient confidentiality, as this patient is a potential victim of elder abuse and that is always reportable


Context: A 57-year-old woman comes to the physician because of a 3-month history of easy fatigability and dyspnea on exertion. Menopause occurred 5 years ago. Her pulse is 105/min and blood pressure is 100/70 mm Hg. Physical examination shows pallor of the nail beds and conjunctivae. A peripheral blood smear shows small, pale red blood cells. Further evaluation is most likely to show which of the following findings?

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

Answer: Positive stool guaiac test


Context: A 56-year-old man with a significant past medical history of diabetes mellitus, hypertension, and hypercholesterolemia is brought to the emergency department by his wife. The wife states the symptoms started 1 hour ago when she noticed that he was having difficulty swallowing his breakfast and that his voice was hoarse. The patient had a recent admission for a transient ischemic attack but was not compliant with his discharge instructions and medication. Examination of the eye shows left-sided partial ptosis and miosis along with diplopia and nystagmus. During the examination, it is noted that the right side of the face and body has markedly more sweating than the left side. An MRI of the brain reveals an ischemic infarct at the level of the left lateral medulla. Which of the following most likely accounts for this patient’s symptoms?

Question: Which of the following most likely accounts for this patient’s symptoms?

Answer: Denervation of the descending sympathetic tract


Context: A 66-year-old female presents to the emergency room with left hip pain after a fall. She is unable to move her hip due to pain. On exam, her left leg appears shortened and internally rotated. Hip radiographs reveal a fracture of the left femoral neck. She has a history of a distal radius fracture two years prior. Review of her medical record reveals a DEXA scan from two years ago that demonstrated a T-score of -3.0. Following acute management of her fracture, she is started on a medication that is known to induce osteoclast apoptosis. Which of the following complications is most closely associated with the medication prescribed in this case?

Question: Which of the following complications is most closely associated with the medication prescribed in this case?

Answer: Osteonecrosis of the jaw


Context: A 32-year-old woman visits her family physician for a routine health check-up. During the consult, she complains about recent-onset constipation, painful defecation, and occasional pain with micturition for the past few months. Her menstrual cycles have always been regular with moderate pelvic pain during menses, which is relieved with pain medication. However, in the last 6 months, she has noticed that her menses are “heavier” with severe lower abdominal cramps that linger for 4–5 days after the last day of menstruation. She and her husband are trying to conceive a second child, but lately, she has been unable to have sexual intercourse due to pain during sexual intercourse. During the physical examination, she has tenderness in the lower abdomen with no palpable mass. Pelvic examination reveals a left-deviated tender cervix, a tender retroverted uterus, and a left adnexal mass. During the rectovaginal examination, nodules are noted. What is the most likely diagnosis for this patient?

Question: What is the most likely diagnosis for this patient?

Answer: Endometriosis


Context: A 67-year-old woman comes to the physician for chest tightness, shortness of breath, and lightheadedness. She has experienced these symptoms during the past 2 weeks while climbing stairs but feels better when she sits down. She had a cold 2 weeks ago but has otherwise been well. She appears short of breath. Her respirations are 21/min and blood pressure is 131/85 mmHg. On cardiovascular examination, a late systolic ejection murmur is heard best in the third right intercostal space. The lungs are clear to auscultation. Which of the following mechanisms is the most likely cause of this patient's current condition?

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

Answer: Increased left ventricular oxygen demand


Context: A 23-year-old woman presents to the emergency room for a self-inflicted laceration of her distal volar forearm. The patient states that she knew her husband was having sexual thoughts about the woman from the grocery store, prompting her decision to cut her own wrist. In the emergency department the bleeding is stopped and the patient is currently medically stable. When interviewing the patient, she is teary and apologizes for her behavior. She is grateful to you for her care and regrets her actions. Of note, the patient has presented to the emergency department before for a similar reason when she was struggling with online dating. The patient states that she struggles with her romantic relationship though she deeply desires them. On physical exam you note a frightened young woman who is wearing a revealing dress that prominently displays her breasts. You tell the patient that she will have to stay in the psychiatric emergency department for the night which makes her furious. Which of the following personality disorders is the most likely diagnosis?

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

Answer: Borderline


Context: An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

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

Answer: Conduct disorder


Context: A 61-year-old man is found dead in his home after his neighbors became concerned when they did not see him for several days. The man was described as a "recluse" who lived alone and mostly kept to himself. Medical records reveal that he had not seen a physician in over a decade. He had a known history of vascular disease including hypertension, hyperlipidemia, and diabetes mellitus. He did not take any medications for these conditions. An autopsy is performed to identify the cause of death. Although it is determined that the patient suffered from a massive cerebrovascular accident as the cause of death, an incidental finding of a tumor arising from the spinal cord meninges is noted. The tumor significantly compresses the left anterolateral lower thoracic spinal cord. The right side of the spinal cord and the posterior spinal cord appear normal. Which of the following would most likely be impaired due to this lesion?

Question: Which of the following would most likely be impaired due to this lesion?

Answer: Pain sensation from the right side of the body


Context:
A 48-year-old woman comes to the physician for the evaluation of 24-hour blood pressure monitoring results. Over the last 3 months, she has had intermittent nausea, decreased appetite, and increasing weakness and fatigue during the day. She has been treated twice for kidney stones within the past year. Her current medications include lisinopril, amlodipine, and furosemide. She is 178 cm (5 ft 10 in) tall and weighs 97 kg (214 lb); BMI is 31 kg/m2. Her blood pressure is 152/98 mm Hg. Physical examination shows no abnormalities. Serum studies show:
Na+ 141 mEq/L
Cl− 101 mEq/L
K+ 4.5 mEq/L
HCO3− 24 mEq/L
Calcium 12.9 mg/dL
Creatinine 1.0 mg/dL
Twenty-four-hour blood pressure monitoring indicates elevated nocturnal blood pressure. Further evaluation is most likely to show which of the following findings?"

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

Answer: Increased serum parathyroid hormone


Context:
A 3-year-old boy is brought to the emergency department by his mother. His mother reports that she found him playing under the sink yesterday. She was concerned because she keeps some poisons for pest control under the sink but did not believe that he came in contact with the poisons. However, this morning the boy awoke with abdominal pain and epistaxis, causing her to rush him to the emergency department.

You obtain stat lab-work with the following results:
WBC: 6,000/microliter;
Hgb: 11.2 g/dL;
Platelets: 200,000/microliter;
PTT: 35 seconds;
INR: 6.5;
Na: 140 mEq/L;
K: 4 mEq/L;
Cr: 0.7 mg/dL.

Which of the following is likely to be the most appropriate treatment?

Question: Which of the following is likely to be the most appropriate treatment?

Answer: Vitamin K and fresh frozen plasma


Context: A six-month-old male presents to the pediatrician for a well-child visit. The patient’s mother is concerned about the patient’s vision because he often turns his head to the right. She has begun trying to correct the head turn and places him on his back with his head turned in the opposite direction to sleep, but she has not noticed any improvement. She is not certain about when the head turning began and denies any recent fever. She reports that the patient fell off the bed yesterday but was easily soothed afterwards. The patient is otherwise doing well and is beginning to try a variety of solid foods. The patient is sleeping well at night. He is beginning to babble and can sit with support. The patient was born at 37 weeks gestation via cesarean delivery for breech positioning. On physical exam, the patient’s head is turned to the right and tilted to the left. There is some minor bruising on the posterior aspect of the head and over the sternocleidomastoid. He has no ocular abnormalities and is able to focus on his mother from across the room. Which of the following is the best next step in management?

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

Answer: Neck radiograph


Context: A previously healthy 27-year-old woman comes to the physician because of a 3-week history of fatigue, headache, and dry cough. She does not smoke or use illicit drugs. Her temperature is 37.8°C (100°F). Chest examination shows mild inspiratory crackles in both lung fields. An x-ray of the chest shows diffuse interstitial infiltrates bilaterally. A Gram stain of saline-induced sputum shows no organisms. Inoculation of the induced sputum on a cell-free medium that is enriched with yeast extract, horse serum, cholesterol, and penicillin G grows colonies that resemble fried eggs. Which of the following organisms was most likely isolated on the culture medium?

Question: Which of the following organisms was most likely isolated on the culture medium?

Answer: Mycoplasma pneumoniae


Context: A 29-year-old Mediterranean man presents to the clinic for fatigue and lightheadedness for the past week. He reports an inability to exercise as his heart would beat extremely fast. He was recently diagnosed with active tuberculosis and started on treatment 2 weeks ago. He denies fever, weight loss, vision changes, chest pain, dyspnea, or bloody/dark stools. A physical examination is unremarkable. A peripheral blood smear is shown in figure A. What is the most likely explanation for this patient’s symptoms?

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

Answer: Drug-induced deficiency in vitamin B6


Context: Two hours after delivery, a 1900-g (4-lb 3-oz) female newborn develops respiratory distress. She was born at 32 weeks' gestation. Pregnancy was complicated by pregnancy-induced hypertension. Her temperature is 36.8°C (98.2°F), pulse is 140/min and respirations are 64/min. Examination shows bluish extremities. Grunting and moderate subcostal retractions are present. There are decreased breath sounds bilaterally on auscultation. An x-ray of the chest shows reduced lung volume and diffuse reticulogranular densities. Supplemental oxygen is administered. Which of the following is the most appropriate next best step in management?

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

Answer: Continous positive airway pressure ventilation


Context: An 18-year-old man presents to the student health department at his university for recurrent palpitations. The patient had previously presented to the emergency department (ED) for sudden onset palpitations five months ago when he first started college. He had a negative cardiac workup in the ED and he was discharged with a 24-hour Holter monitor which was also negative. He has no history of any medical or psychiatric illnesses. The patient reports that since his initial ED visit, he has had several episodes of unprovoked palpitations associated with feelings of dread and lightheadedness though he cannot identify a particular trigger. Recently, he has begun sitting towards the back of the lecture halls so that he can “quickly escape and not make a scene” in case he gets an episode in class. Which of the following is the most likely diagnosis?

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

Answer: Panic disorder


Context: A 62-year-old woman is brought to the physician because of 6 months of progressive weakness in her arms and legs. During this time, she has also had difficulty swallowing and holding her head up. Examination shows pooling of oral secretions. Muscle strength and tone are decreased in the upper extremities. Deep tendon reflexes are 1+ in the right upper and lower extremities, 3+ in the left upper extremity, and 4+ in the left lower extremity. Sensation to light touch, pinprick, and vibration are intact. Which of the following is the most likely diagnosis?

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

Answer: Amyotrophic lateral sclerosis


Context: A 46-year-old man diagnosed with pancreatic adenocarcinoma is admitted with fever, malaise, and dyspnea. He says that symptoms onset 2 days ago and have progressively worsened. Past medical history is significant for multiple abdominal surgeries including stenting of the pancreatic duct. Current inpatient medications are rosuvastatin 20 mg orally daily, aspirin 81 mg orally daily, esomeprazole 20 mg orally daily, oxycontin 10 mg orally twice daily, lorazepam 2 mg orally 3 times daily PRN, and ondansetron 10 mg IV. On admission, his vital signs include blood pressure 105/75 mm Hg, respirations 22/min, pulse 90/min, and temperature 37.0°C (98.6°F). On his second day after admission, the patient acutely becomes obtunded. Repeat vital signs show blood pressure 85/55 mm Hg, respirations 32/min, pulse 115/min. Physical examination reveals multiple ecchymoses on the trunk and extremities and active bleeding from all IV and venipuncture sites. There is also significant erythema and swelling of the posterior aspect of the left leg. Laboratory findings are significant for thrombocytopenia, prolonged PT and PTT, and an elevated D-dimer. Blood cultures are pending. Which of the following is most likely responsible for this patient’s current condition?

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

Answer: Disseminated intravascular coagulation


Context: A 1-day-old neonate is being evaluated for a rash.  The neonate was born at 39 weeks’ gestation to a gravida 3, para 2 immigrant from Guatemala with no prenatal care. Her previous pregnancies were uneventful. She has no history of group B strep screening, and she was given an injection of penicillin prior to delivery. Apgar scores were 7 and 9 at 1 and 5 minutes respectively. The newborn’s vitals are temperature 37°C (98.6°F), pulse is 145/min, and respirations are 33/min.  A machine like a murmur is heard when auscultating the heart. There is a diffuse purpuric rash as seen in the image. Which of the following is the most likely cause of this patient’s infection?

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

Answer: Rubella


Context: A 19-year-old man comes to the physician for evaluation of night sweats, pruritus, and enlarging masses in his right axilla and supraclavicular area for 2 weeks. Physical examination shows painless, rubbery lymphadenopathy in the right axillary, supraclavicular, and submental regions. An excisional biopsy of an axillary node is performed. If present, which of the following features would be most concerning for a neoplastic process?

Question: If present, which of the following features would be most concerning for a neoplastic process?

Answer: Preponderance of lymphocytes with a single immunoglobulin variable domain allele


Context: A 32-year-old man comes to the office for a routine health maintenance examination. He admits to recently having an affair several months ago and requests STD testing. One week later, the results of a fourth-generation HIV antibody and antigen test return positive. The patient is counseled on the test result. The patient requests that his diagnosis not be disclosed to anyone, including his wife. The man's wife is also the physician's patient. Which of the following is the most appropriate next step by the physician?

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

Answer: Report the infection to the national health authorities


Context: A 47-year-old man presents with daily substernal chest pain for the past year. In addition, he says that he often suffers from hoarseness and a cough in the mornings. His wife has also reported that he has developed bad breath. Past medical history is significant for diabetes mellitus, managed with metformin. His physical examination is unremarkable. ECG is normal. An esophagogastroduodenoscopy is performed. The lower third of the esophagus appears erythematous, and a biopsy of the gastroesophageal junction is taken. When he is given sublingual nitroglycerin, it is noted that his chest discomfort is worsened. Which of the following would be expected in this patient’s biopsy?

Question: Which of the following would be expected in this patient’s biopsy?

Answer: Simple columnar epithelium


Context: A 49-year-old woman presents to her primary care physician with fatigue. She reports that she has recently been sleeping more than usual and says her “arms and legs feel like lead” for most of the day. She has gained 10 pounds over the past 3 months which she attributes to eating out at restaurants frequently, particularly French cuisine. Her past medical history is notable for social anxiety disorder. She took paroxetine and escitalopram in the past but had severe nausea and headache while taking both. She has a 10 pack-year smoking history and has several glasses of wine per day. Her temperature is 98.6°F (37°C), blood pressure is 130/65 mmHg, pulse is 78/min, and respirations are 16/min. Physical examination reveals an obese woman with a dysphoric affect. She states that her mood is sad but she does experience moments of happiness when she is with her children. The physician starts the patient on a medication to help with her symptoms. Three weeks after the initiation of the medication, the patient presents to the emergency room with a severe headache and agitation. Her temperature is 102.1°F (38.9°C), blood pressure is 180/115 mmHg, pulse is 115/min, and respirations are 24/min. Which of the following is the mechanism of action of the medication that is most likely responsible for this patient’s symptoms?

Question: Which of the following is the mechanism of action of the medication that is most likely responsible for this patient’s symptoms?

Answer: Inhibition of amine degradation


Context: A 40-year-old man is brought to an urgent care clinic by his wife with complaints of dizziness and blurring of vision for several hours. His wife adds that he has had slurred speech since this morning and complained of difficulty swallowing last night. His wife mentions that her husband was working outdoors and ate stew with roasted beef and potatoes that had been sitting on the stove for the past 3 days. The patient's past medical history is unremarkable. A physical examination reveals right eye ptosis and palatal weakness with an impaired gag reflex. Cranial nerve examination reveals findings suggestive of CN V and VII lesions. What is the mechanism of action of the toxin that is the most likely cause of this patient’s symptoms?

Question: What is the mechanism of action of the toxin that is the most likely cause of this patient’s symptoms?

Answer: Inhibition of the release of acetylcholine


Context: A 21-year-old woman comes to the physician because of a 2-month history of fatigue, intermittent abdominal pain, and bulky, foul-smelling diarrhea. She has had a 4-kg (8-lb 12-oz) weight loss during this period despite no changes in appetite. Examination of the abdomen shows no abnormalities. Staining of the stool with Sudan III stain shows a large number of red droplets. Which of the following is the most likely underlying cause of this patient’s symptoms?

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

Answer: Celiac disease


Context: A 22-year-old female presents to her PCP after having unprotected sex with her boyfriend 2 days ago. She has been monogamous with her boyfriend but is very concerned about pregnancy. The patient requests emergency contraception to decrease her likelihood of getting pregnant. A blood hCG test returns negative. The PCP prescribes the patient ethinyl estradiol 100 mcg and levonorgestrel 0.5 mg to be taken 12 hours apart. What is the most likely mechanism of action for this combined prescription?

Question: What is the most likely mechanism of action for this combined prescription?

Answer: Inhibition or delayed ovulation


Context: A 32-year-old HIV positive male presents to the office complaining of difficulty swallowing and bad breath for the past couple of months. Upon further questioning, he says, "it feels like there’s something in my throat". He says that the difficulty is sometimes severe enough that he has to skip meals. He added that it mainly occurs with solid foods. He is concerned about his bad breath since he has regular meetings with his clients. Although he is on antiretroviral medications, he admits that he is noncompliant. On examination, the patient is cachectic with pale conjunctiva. On lab evaluation, the patient’s CD4+ count is 70/mm3. What is the most likely cause of his symptoms?

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

Answer: Candida albicans


Context: A 45-year-old man presents for follow-up to monitor his chronic hepatitis C treatment. The patient was infected with hepatitis C genotype 1, one year ago. He has been managed on a combination of pegylated interferon-alpha and ribavirin, but a sustained viral response has not been achieved. Past medical history is significant for non-alcoholic fatty liver disease for the last 5 years. Which of the following, if added to the patient’s current treatment regimen, would most likely benefit this patient?

Question: Which of the following, if added to the patient’s current treatment regimen, would most likely benefit this patient?

Answer: Simeprevir


Context: A 65-year-old man is brought to the emergency department after coughing up copious amounts of blood-tinged sputum at his nursing home. He recently had an upper respiratory tract infection that was treated with antibiotics. He has a long-standing history of productive cough that has worsened since he had a stroke 3 years ago. He smoked a pack of cigarettes daily for 40 years until the stroke, after which he quit. The patient appears distressed and short of breath. His temperature is 38°C (100.4°F), pulse is 92/min, and blood pressure is 145/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Physical examination shows digital clubbing and cyanosis of the lips. Coarse crackles are heard in the thorax. An x-ray of the chest shows increased translucency and tram-track opacities in the right lower lung field. Which of the following is the most likely diagnosis?

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

Answer: Bronchiectasis


Context: An 11-month-old boy is brought to a pediatrician by his parents with a recurrent cough, which he has had since the age of 2 months. He has required 3 hospitalizations for severe wheezing episodes. His mother also mentions that he often has diarrhea. The boy’s detailed history reveals that he required hospitalization for meconium ileus during the neonatal period. Upon physical examination, his temperature is 37.0°C (98.6ºF), pulse rate is 104/min, respiratory rate is 40/min, and blood pressure is 55/33 mm Hg. An examination of the boy’s respiratory system reveals the presence of bilateral wheezing and scattered crepitations. An examination of his cardiovascular system does not reveal any abnormality. His length is 67.3 cm (26.5 in) and weight is 15 kg (33 lbs). His sweat chloride level is 74 mmol/L. His genetic evaluation confirms that he has an autosomal recessive disorder resulting in a dysfunctional membrane-bound protein.  Which of the following best describes the mechanism associated with the most common mutation that causes this disorder?

Question: Which of the following best describes the mechanism associated with the most common mutation that causes this disorder?

Answer: Defective maturation and early degradation of the protein


Context: A 67-year-old man presents to his family physician’s office for a routine visit and to discuss a growth on his toenail that has been gradually enlarging for a month. He has a history of diabetes mellitus, hyperlipidemia, and hypertension and is on metformin, atorvastatin, and lisinopril. He admits to smoking 2 packs of cigarettes daily for the past 45 years. His blood pressure reading today is 132/88 mm Hg, heart rate is 78/min, respiration rate is 12/min and his temperature is 37.1°C (98.8°F). On exam, the patient appears alert and in no apparent distress. Capillary refill is 3 seconds. Diminished dull and sharp sensations are present bilaterally in the lower extremities distal to the mid-tibial region. An image of the patient’s toenail is provided. A potassium hydroxide (KOH) preparation of a nail clipping sample confirms the presence of hyphae. Which of the following treatment options will be most effective for this condition?

Question: Which of the following treatment options will be most effective for this condition?

Answer: Terbinafine


Context: A 53-year-old woman presents to her primary care physician due to her “feet feeling painful.” She reports initially having decreased sensation on both of her feet and recently her hands. She now experiences paresthesias, numbness, and a “burning pain.” She is recovering from a recent myocardial infarction. Approximately 1.5 weeks ago, she experienced mild watery diarrhea and an atypical pneumonia. For the past 3 weeks, she has been experiencing fatigue, trouble with concentration, and mild weight gain. Beyond this she has no other acute concerns. Her past medical history is significant for type II diabetes mellitus, hypertension, and coronary artery disease. She is currently taking metformin, aspirin, artovastatin, metoprolol, and lisinopril. Her temperature is 99°F (37.2°C), blood pressure is 155/98 mmHg, pulse is 85/min, and respirations are 14/min. On physical exam, there is a loss of vibratory sensation and altered proprioception in the bilateral feet. She has impaired pain, light touch, and temperature sensation starting from her feet to mid-calf and hands. She has normal strength and muscle tone throughout her upper and lower extremities, as well as absent bilateral ankle reflexes. Which of the following is the best next step in management?

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

Answer: Gabapentin


Context: A 52-year-old man comes to the physician because of a 3-day history of intermittent chest tightness that worsens with exercise. He has chronic atrial fibrillation treated with a drug that prolongs the QT interval. During cardiac stress testing, an ECG shows progressive shortening of the QT interval as the heart rate increases. Which of the following drugs is this patient most likely taking?

Question: Which of the following drugs is this patient most likely taking?

Answer: Dofetilide


Context: A 27-year-old female presents to her primary care physician because she is concerned about lighter colored patches on her skin. She recently went sunbathing and noticed that these areas also did not tan. Her doctor explains that she has a fungal infection of the skin that damages melanocytes by producing acids. She is prescribed selenium sulfide and told to follow-up in one month. Which of the following describes the appearance of the most likely infectious organism under microscopy?

Question: Which of the following describes the appearance of the most likely infectious organism under microscopy?

Answer: "Spaghetti and meatballs" fungus


Context: A 6-month-old girl is brought to the physician for a well-child examination. She was born at 37 weeks' gestation. Pregnancy and the neonatal period were uncomplicated. The infant was exclusively breastfed and received vitamin D supplementation. She can sit unsupported and can transfer objects from one hand to the other. She babbles and is uncomfortable around strangers. She is at 40th percentile for length and at 35th percentile for weight. Vital signs are within normal limits. Physical examination shows no abnormalities. In addition to continuing breastfeeding, which of the following is the most appropriate recommendation at this time?

Question: In addition to continuing breastfeeding, which of the following is the most appropriate recommendation at this time?

Answer: Introduce solid foods and continue vitamin D


Context:
A 23-year-old woman presents to her primary care physician for poor sleep. Her symptoms began approximately 1 week ago, when she started waking up multiple times throughout the night to urinate. She also reports an increase in her water intake for the past few days prior to presentation, as well as larger urine volumes than normal. Medical history is significant for asthma. Family history is significant for type 2 diabetes mellitus. She denies alcohol, illicit drug, or cigarette use. Her temperature is 98.6°F (37°C), blood pressure is 108/65 mmHg, pulse is 103/min, and respirations are 18/min. On physical exam, she has mildly dry mucous membranes and has no focal neurological deficits. Laboratory testing demonstrates the following:

Serum:
Na+: 145 mEq/L
Cl-: 102 mEq/L
K+: 4.2 mEq/L
HCO3-: 28 mEq/L
BUN: 15 mg/dL
Glucose: 98 mg/dL
Creatinine: 0.92 mg/dL

Urine:
Urine osmolality: 250 mOsm/kg

The patient undergoes a water deprivation test, and her labs demonstrate the following:

Na+: 147 mEq/L
Cl-: 103 mEq/L
K+: 4.4 mEq/L
HCO3-: 22 mEq/L
BUN: 16 mg/dL
Glucose: 101 mg/dL
Creatinine: 0.94 mg/dL

Urine osmolality: 252 mOsm/kg

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

Question:
Laboratory testing demonstrates the following:

Serum:
Na+: 145 mEq/L
Cl-: 102 mEq/L
K+: 4.2 mEq/L
HCO3-: 28 mEq/L
BUN: 15 mg/dL
Glucose: 98 mg/dL
Creatinine: 0.92 mg/dL

Urine:
Urine osmolality: 250 mOsm/kg

The patient undergoes a water deprivation test, and her labs demonstrate the following:

Na+: 147 mEq/L
Cl-: 103 mEq/L
K+: 4.4 mEq/L
HCO3-: 22 mEq/L
BUN: 16 mg/dL
Glucose: 101 mg/dL
Creatinine: 0.94 mg/dL

Urine osmolality: 252 mOsm/kg

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

Answer: Desmopressin


Context: A prospective cohort study was conducted to assess the relationship between LDL and the incidence of heart disease. The patients were selected at random. Results showed a 10-year relative risk (RR) of 3.0 for people with elevated LDL levels compared to individuals with normal LDL levels. The p-value was 0.04 with a 95% confidence interval of 2.0-4.0. According to the study results, what percent of heart disease in these patients can be attributed to elevated LDL?

Question: According to the study results, what percent of heart disease in these patients can be attributed to elevated LDL?

Answer: 67%


Context: A 47-year-old woman presents to the emergency department with abdominal pain. The patient states that she felt this pain come on during dinner last night. Since then, she has felt bloated, constipated, and has been vomiting. Her current medications include metformin, insulin, levothyroxine, and ibuprofen. Her temperature is 99.0°F (37.2°C), blood pressure is 139/79 mmHg, pulse is 95/min, respirations are 12/min, and oxygen saturation is 98% on room air. On physical exam, the patient appears uncomfortable. Abdominal exam is notable for hypoactive bowel sounds, abdominal distension, and diffuse tenderness in all four quadrants. Cardiac and pulmonary exams are within normal limits. Which of the following is the best next step in management?

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

Answer: Nasogastric tube, NPO, and IV fluids


Context: A 60-year-old male presents with palpitations. He reports drinking many glasses of wine over several hours at a family wedding the previous evening. An EKG reveals absent P waves and irregularly irregular rhythm. He does not take any medications. Which is most likely responsible for the patient’s symptoms?

Question: Which is most likely responsible for the patient’s symptoms?

Answer: Atrial fibrillation


Context:
A 66-year-old man presents to the emergency department with a 3-hour history of crushing chest pain radiating to the left shoulder and neck. Patient states that the pain began suddenly when he was taking a walk around the block and has not improved with rest. He also mentions difficulty breathing and prefers to sit leaning forward. He denies ever having similar symptoms before. Past medical history is significant for hypertension, diagnosed 10 years ago, and hyperlipidemia diagnosed 8 years ago. Current medications are atorvastatin. Patient is also prescribed hydrochlorothiazide as an antihypertensive but is not compliant because he says it makes him urinate too often.
Vitals show a blood pressure of 152/90 mm Hg, pulse of 106/min, respirations of 22/min and oxygen saturation of 97% on room air. On physical exam, patient is profusely diaphoretic and hunched over in distress. Cardiac exam is unremarkable and lungs are clear to auscultation. During your examination, the patient suddenly becomes unresponsive and a pulse cannot be palpated. A stat ECG shows the following (see image). Which of the following is the next best step in management?

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

Answer: Unsynchronized cardioversion


Context:
A 3-year-old boy presents to the clinic for evaluation of leg pain. This has been persistent for the past 3 days and accompanied by difficulty walking. He has also had some erythema and ecchymoses in the periorbital region over the same time period. The vital signs are unremarkable. The physical exam notes the above findings, as well as some swelling of the upper part of the abdomen. The laboratory results are as follows:
Erythrocyte count 3.3 million/mm3
Leukocyte count 3,000/mm3
Neutrophils 54%
Eosinophils 1%
Basophils 55%
Lymphocytes 30%
Monocytes 3%
Platelet count 80,000/mm3
A magnetic resonance image (MRI) scan of the abdomen shows a mass of adrenal origin. Which of the following is the most likely cause of this patient’s symptoms?

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

Answer: Neuroblastoma


Context:
A 12-year-old boy who recently immigrated from Namibia is being evaluated for exertional shortness of breath and joint pain for the past month. His mother reports that he used to play soccer but now is unable to finish a game before he runs out of air or begins to complain of knee pain. He was a good student but his grades have recently been declining over the past few months. The mother recalls that he had a sore throat and didn’t go to school for 3 days a few months ago. He had chickenpox at the age of 5 and suffers from recurrent rhinitis. He is currently taking over-the-counter multivitamins. His blood pressure is 110/90 mm Hg, pulse rate is 55/min, and respiratory rate is 12/min. On physical examination, subcutaneous nodules are noted on his elbows bilaterally. On cardiac auscultation, a holosystolic murmur is heard over the mitral area that is localized. Lab work shows:
Hemoglobin 12.9 g/dL
Hematocrit 37.7%
Leukocyte count 5,500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 fL
Platelet count 139,000/mm3
Erythrocyte sedimentation rate 35 mm/h
C-reactive protein 14 mg/dL
Antistreptolysin O (ASO) 400 IU (normal range: > 200 IU)
Which is the mechanism behind the cause of this boy’s symptoms?

Question:
Lab work shows:
Hemoglobin 12.9 g/dL
Hematocrit 37.7%
Leukocyte count 5,500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 fL
Platelet count 139,000/mm3
Erythrocyte sedimentation rate 35 mm/h
C-reactive protein 14 mg/dL
Antistreptolysin O (ASO) 400 IU (normal range: > 200 IU)
Which is the mechanism behind the cause of this boy’s symptoms?

Answer: Type II hypersensitivity reaction


Context:
A 67-year-old man comes to the emergency department for the evaluation of two episodes of red urine since this morning. He has no pain with urination. He reports lower back pain and fever. Six months ago, he was diagnosed with osteoarthritis of the right knee that he manages with 1–2 tablets of ibuprofen per day. He has smoked one pack of cigarettes daily for the past 45 years. He does not drink alcohol. His temperature is 38.5°C (101.3°F), pulse is 95/min, and blood pressure is 130/80 mm Hg. Physical examination shows faint, diffuse maculopapular rash, and bilateral flank pain. The remainder of the examination shows no abnormalities. Urinalysis shows:
Blood +3
Protein +1
RBC 10–12/hpf
RBC cast negative
Eosinophils numerous
Which of the following is the most likely diagnosis?"

Question:
Urinalysis shows:
Blood +3
Protein +1
RBC 10–12/hpf
RBC cast negative
Eosinophils numerous
Which of the following is the most likely diagnosis?"

Answer: Acute tubulointerstitial nephritis


Context: A 56-year-old African American woman comes to the physician because of frequent urination. For the past year, she has had to urinate multiple times every hour. She has been thirstier and hungrier than usual. She has not had any pain with urination. She has no time to exercise because she works as an accountant. Her diet mostly consists of pizza and cheeseburgers. Her vital signs are within normal limits. Physical examination shows no abnormalities. Today, her blood glucose level is 200 mg/dL and her hemoglobin A1c is 7.4%. Urinalysis shows microalbuminuria. Which of the following is the most likely cause of this patient's proteinuria?

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

Answer: Increased glomerular filtration


Context: A 45-year-old man presents to an ambulatory clinic for evaluation after feeling food stuck behind the sternum when he was eating a hamburger last night. He was not in pain. He had to drink a whole glass of water to get the food down; however, he did manage to finish his dinner without any further problems. He is concerned because he has had 2 similar episodes this year. He is otherwise healthy. He has smoked 1 half-pack of cigarettes a day for 20 years and enjoys a can of beer every night. His vital signs are as follows: blood pressure 125/75 mm Hg, pulse 68/min, respiratory rate 14/min, and temperature 36.5°C (97.7°F). His oral examination reveals 2 decayed teeth. The physical exam is otherwise unremarkable. An endoscopic image of the lower esophagus is shown. Which of the following is the most appropriate next step in management?

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

Answer: Endoscopic dilation


Context: An 82-year-old male with congestive heart failure experiences rapid decompensation of his condition, manifesting as worsening dyspnea, edema, and increased fatigue. Labs reveal an increase in his serum creatinine from baseline. As part of the management of this acute change, the patient is given IV dobutamine to alleviate his symptoms. Which of the following effects occur as a result of this therapy?

Question: Which of the following effects occur as a result of this therapy?

Answer: Increased myocardial oxygen consumption


Context: A neurophysiology expert is teaching his students the physiology of the neuromuscular junction. While describing the sequence of events that takes place at the neuromuscular junction, he mentions that as the action potential travels down the motor neuron, it causes depolarization of the presynaptic membrane. This results in the opening of voltage-gated calcium channels, which leads to an influx of calcium into the synapse of the motor neuron. Consequently, the cytosolic concentration of Ca2+ ions increases. Which of the following occurs at the neuromuscular junction as a result of this increase in cytosolic Ca2+?

Question: Which of the following occurs at the neuromuscular junction as a result of this increase in cytosolic Ca2+?

Answer: Exocytosis of acetylcholine from the synaptic vesicles


Context: A scientist is trying to determine the proportion of white-eyed fruit flies in the environment. The white-eyed allele was found to be dominant to the red-eyed allele. The frequency of the red-eyed allele is 0.1. What is the proportion of flies who have white-eyes if the population is in Hardy Weinberg Equilibrium?

Question: What is the proportion of flies who have white-eyes if the population is in Hardy Weinberg Equilibrium?

Answer: 99%


Context: An investigator is studying muscle contraction in tissue obtained from the thigh muscle of an experimental animal. After injection of radiolabeled ATP, the tissue is stimulated with electrical impulses. Radioassay of these muscle cells is most likely to show greatest activity in which of the following structures?

Question: Radioassay of these muscle cells is most likely to show greatest activity in which of the following structures?

Answer: A band


Context: A 15-month-old boy presents to his family physician after being brought in by his mother. She is concerned that her son has been sick for more than 5 days, and he is not getting better with home remedies and acetaminophen. On examination, the child has a sore throat and obvious congestion in the maxillary sinuses. His temperature is 37.6°C (99.6°F). An infection with Haemophilus influenzae is suspected, and a throat sample is taken and sent to the laboratory for testing. The child is at the lower weight-for-length percentile. His history indicates he previously had an infection with Streptococcus pneumoniae in the last 4 months, which was treated effectively with antibiotics. While waiting for the laboratory results, and assuming the child’s B and T cell levels are normal, which of the following diagnoses is the physician likely considering at this time?

Question: While waiting for the laboratory results, and assuming the child’s B and T cell levels are normal, which of the following diagnoses is the physician likely considering at this time?

Answer: Hyper-IgM syndrome


Context: Health officials are considering a change be made to the interpretation of the tuberculin skin test that will change the cut-off for a positive purified protein derivative (PPD) from 10 mm to 15 mm for healthcare workers. Which of the following can be expected as a result of this change?

Question: Which of the following can be expected as a result of this change?

Answer: Decrease the sensitivity


Context:
A 54-year-old woman comes to the office complaining of increased urinary frequency and dysuria. She is accompanied by her husband. The patient reports that she goes to the bathroom 6-8 times a day. Additionally, she complains of pain at the end of her urinary stream. She denies fever, abdominal pain, vaginal discharge, or hematuria. Her husband adds, “we also don’t have sex as much as we used to.” The patient reports that even when she is “in the mood,” sex is “no longer pleasurable.” She admits feeling guilty about this. The patient’s last menstrual period was 15 months ago. Her medical history is significant for hyperlipidemia and coronary artery disease. She had a non-ST elevation myocardial infarction (NSTEMI) 3 months ago, and she has had multiple urinary tract infections (UTIs) in the past year. She smokes 1 pack of cigarettes a day and denies alcohol or illicit drug use. Body mass index is 32 kg/m^2. Pelvic examination reveals vaginal dryness and vulvar tissue thinning. A urinalysis is obtained as shown below:

Urinalysis
Glucose: Negative
WBC: 25/hpf
Bacterial: Many
Leukocyte esterase: Positive
Nitrites: Positive

The patient is prescribed a 5-day course of nitrofurantoin. Which of the following is the most appropriate additional management for the patient’s symptoms?

Question: Which of the following is the most appropriate additional management for the patient’s symptoms?

Answer: Topical estrogen


Context: A 13-year-old boy is brought to the emergency department after being involved in a motor vehicle accident in which he was a restrained passenger. He is confused and appears anxious. His pulse is 131/min, respirations are 29/min, and blood pressure is 95/49 mm Hg. Physical examination shows ecchymosis over the upper abdomen, with tenderness to palpation over the left upper quadrant. There is no guarding or rigidity. Abdominal ultrasound shows free intraperitoneal fluid and a splenic rupture. Intravenous fluids and vasopressors are administered. A blood transfusion and exploratory laparotomy are scheduled. The patient's mother arrives and insists that her son should not receive a blood transfusion because he is a Jehovah's Witness. The physician proceeds with the blood transfusion regardless of the mother's wishes. The physician's behavior is an example of which of the following principles of medical ethics?

Question: The physician's behavior is an example of which of the following principles of medical ethics?

Answer: Beneficence


Context: A 25 year-old woman is brought to the emergency department by her boyfriend after she cut her forearms with a knife. She has had multiple visits to the emergency department in the past few months for self-inflicted wounds. She claims that her boyfriend is the worst person in the world. She and her boyfriend have broken up 20 times in the past 6 months. She says she cut herself not because she wants to kill herself; she feels alone and empty and wants her boyfriend to take care of her. Her boyfriend claims that she is prone to outbursts of physical aggression as well as mood swings. He says that these mood swings last a few hours and vary from states of exuberance and self-confidence to states of self-doubt and melancholy. On examination, the patient appears well-dressed and calm. She has normal speech, thought processes, and thought content. Which of the following is the most likely diagnosis?

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

Answer: Borderline personality disorder


Context: A 62-year-old man presents to the emergency department with acute pain in the left lower abdomen and profuse rectal bleeding. These symptoms started 3 hours ago. The patient has chronic constipation and bloating, for which he takes lactulose. His family history is negative for gastrointestinal disorders. His temperature is 38.2°C (100.8°F), blood pressure is 90/60 mm Hg, and pulse is 110/min. On physical examination, the patient appears drowsy, and there is tenderness with guarding in the left lower abdominal quadrant. Flexible sigmoidoscopy shows multiple, scattered diverticula with acute mucosal inflammation in the sigmoid colon. Which of the following is the best initial treatment for this patient?

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

Answer: Volume replacement, analgesia, intravenous antibiotics, and endoscopic hemostasis


Context: An investigator is studying the effects of different drugs on the contraction of cardiomyocytes. The myocytes are able to achieve maximal contractility with the administration of drug A. The subsequent administration of drug B produces the response depicted in the graph shown. Which of the following drugs is most likely to produce a response similar to that of drug B?

Question: Which of the following drugs is most likely to produce a response similar to that of drug B?

Answer: Pindolol


Context: A 65-year-old woman comes to the physician for the evaluation of several episodes of urinary incontinence over the past several months. She reports that she was not able to get to the bathroom in time. During the past 6 months, her husband has noticed that she is starting to forget important appointments and family meetings. She has type 2 diabetes mellitus treated with metformin. The patient had smoked a pack of cigarettes daily for 45 years. Her vital signs are within normal limits. On mental status examination, she is confused and has short-term memory deficits. She walks slowly taking short, wide steps. Muscle strength is normal. Deep tendon reflexes are 2+ bilaterally. Which of the following is the most likely underlying cause of this patient's urinary incontinence?

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

Answer: Inability to suppress voiding


Context:
A 32-year-old man presents with a history of diarrhea several days after eating a hot dog at a neighborhood barbeque. He notes that the diarrhea is visibly bloody, but he has not experienced a fever. He adds that several other people from his neighborhood had similar complaints, many of which required hospitalization after eating food at the same barbeque. His temperature is 37°C (98.6°F ), respiratory rate is 16/min, pulse is 77/min, and blood pressure is 100/88 mm Hg. A physical examination is performed and is within normal limits. Blood is drawn for laboratory testing. The results are as follows:
Hb%: 12 gm/dL
Total count (WBC): 13,100/mm3
Differential count:
Neutrophils: 80%
Lymphocytes: 15%
Monocytes: 5%
ESR: 10 mm/hr
Glucose, Serum: 90 mg/dL
BUN: 21 mg/dL
Creatinine, Serum: 1.96 mg/dL
Sodium, Serum: 138 mmol/L
Potassium, Serum: 5.2 mmol/L
Chloride, Serum: 103 mmol/L
Bilirubin, Total: 2.5 mg/dL
Alkaline Phosphatase, Serum: 66 IU/L
Aspartate aminotransferase (AST): 32 IU/L
Alanine aminotransferase (ALT): 34 IU/L
Urinalysis is normal except for RBC casts. Which are the most concerning possible complication?

Question: Which are the most concerning possible complication?

Answer: Hemolytic uremic syndrome


Context: A 25-year-old man comes to the physician for severe back pain. He describes the pain as shooting and stabbing. On a 10-point scale, he rates the pain as a 9 to 10. The pain started after he lifted a heavy box at work; he works at a supermarket and recently switched from being a cashier to a storekeeper. The patient appears to be in severe distress. Vital signs are within normal limits. On physical examination, the spine is nontender without paravertebral muscle spasms. Range of motion is normal. A straight-leg raise test is negative. After the physical examination has been completed, the patient asks for a letter to his employer attesting to his inability to work as a storekeeper. Which of the following is the most appropriate response?

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

Answer: """I understand that you are uncomfortable, but the findings do not match the severity of your symptoms. Let's talk about the recent changes at your job."""


Context: A 27-year-old female presents to her primary care physician with a chief complaint of pain in her lower extremity. The patient states that the pain has gradually worsened over the past month. The patient states that her pain is worsened when she is training. The patient is a business student who does not have a significant past medical history and is currently not on any medications. She admits to having unprotected sex with multiple partners and can not recall her last menses. She drinks 7 to 10 shots of liquor on the weekends and smokes marijuana occasionally. She recently joined the cross country team and has been training for an upcoming meet. Her temperature is 99.5°F (37.5°C), pulse is 88/min, blood pressure is 100/70 mmHg, respirations are 10/min, and oxygen saturation is 97% on room air. On physical exam you note a very pale young woman in no current distress. Pain is localized to the lateral aspect of the knee and is reproduced upon palpation. Physical exam of the knee, hip, and ankle is otherwise within normal limits. The patient has 1+ reflexes and 2+ strength in all extremities. A test for STI's performed one week ago came back negative for infection. Which of the following is the most likely explanation for this patient's presentation?

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

Answer: Friction with the lateral femoral epicondyle


Context:
A 59-year-old man presents to his primary care physician for fatigue. In general, he has been in good health; however, he recently has experienced some weight loss, abdominal pain, and general fatigue. He has a past medical history of anxiety, diabetes, a fracture of his foot sustained when he tripped, and a recent cold that caused him to miss work for a week. His current medications include metformin, insulin, buspirone, vitamin D, calcium, and sodium docusate. His temperature is 99.5°F (37.5°C), blood pressure is 150/100 mmHg, pulse is 90/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam reveals a calm gentleman. A mild systolic murmur is heard in the left upper sternal region. The rest of the physical exam is within normal limits. Laboratory values are ordered as seen below.

Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 66,500/mm^3 with normal differential
Platelet count: 177,000/mm^3
Leukocyte alkaline phosphatase: elevated

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
BUN: 20 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.9 mEq/L
AST: 12 U/L
ALT: 10 U/L

Which of the following is the most likely diagnosis?

Question:
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 66,500/mm^3 with normal differential
Platelet count: 177,000/mm^3
Leukocyte alkaline phosphatase: elevated

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
BUN: 20 mg/dL
Glucose: 120 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.9 mEq/L
AST: 12 U/L
ALT: 10 U/L

Which of the following is the most likely diagnosis?

Answer: Leukemoid reaction


Context: A 17-year-old male comes to the physician because of painful genital sores, malaise, and fever for 3 days. He is sexually active with 3 female partners and does not use condoms consistently. His temperature is 38.3°C (101°F). Physical examination shows tender lymphadenopathy in the left inguinal region and multiple, punched-out ulcers over the penile shaft and glans. Microscopic examination of a smear from the ulcer is most likely to show which of the following?

Question: Microscopic examination of a smear from the ulcer is most likely to show which of the following?

Answer: Eosinophilic intranuclear inclusions


Context: A 31-year-old woman makes an appointment with a fertility specialist because she has not been able to conceive despite trying for over a year with her husband. She is concerned because her husband has 2 children from a previous marriage whereas she has no children. After obtaining a detailed history as well as lab tests, the specialist prescribes a certain drug. Interestingly, this drug is able to stimulate receptors in the presence of low hormone levels and inhibit the same receptors in the presence of high hormone levels. The drug that is most likely being prescribed in this case is associated with which of the following adverse events?

Question: The drug that is most likely being prescribed in this case is associated with which of the following adverse events?

Answer: Visual disturbances


Context: A 72-year-old man presents to his physician’s office with complaints of a cough and painful breathing for the last 2 months. He says that he has also observed a 5 kg (11 lb) weight loss during the past month. He is relatively healthy but the sudden change in his health worries him. Another problem that he has been facing is the swelling of his face and arms at unusual times of the day. He says that the swelling is more prominent when he is supine. He has also lately been experiencing difficulty with his vision. He consumes alcohol occasionally and quit smoking last year following a 25-year history of smoking. On examination, the patient is noted to have distended veins in the chest and arms. His jugular veins are distended. Physical examination shows ptosis of the right eye and miosis of the right pupil. His lungs are clear to auscultation. He is sent for an X-ray for further evaluation of his condition. Which of the following is the most likely site for the detection of the nodule on CT scan?

Question: Which of the following is the most likely site for the detection of the nodule on CT scan?

Answer: Right upper lobe


Context: A 72-year-old man is brought to the physician by his wife for memory issues over the last 7 months. The patient's wife feels that he has gradually become more forgetful. He commonly misplaces his car keys and forgets his children's names. He seems to have forgotten how to make dinner and sometimes serves uncooked noodles or raw meat. One night he parked his car in a neighbor's bushes and was found wandering the street. He has a history of hypertension, hyperlipidemia, and COPD. Current medications include atorvastatin, metoprolol, ipratropium, and fluticasone. Vital signs are within normal limits. He is alert and oriented to person and place only. Neurologic examination shows no focal findings. His Mini-Mental State Examination score is 19/30. A complete blood count and serum concentrations of electrolytes, urea nitrogen, creatinine, thyroid-stimulating hormone, liver function tests, vitamin B12 (cobalamin), and folate are within the reference range. Which of the following is the most appropriate next step in diagnosis?

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

Answer:
MRI of the brain
"


Context: A 4-month-old girl is brought to the office by her parents because they noticed a mass protruding from her rectum and, she has been producing green colored emesis for the past 24 hours. Her parents noticed the mass when she had a bowel movement while changing her diaper. She strained to have this bowel movement 24 hours ago, shortly afterwards she had 3 episodes of greenish vomiting. She has a past medical history of failure to pass meconium for 2 days after birth. Her vital signs include: heart rate 190/min, respiratory rate 44/min, temperature 37.2°C (99.0°F), and blood pressure 80/50 mm Hg. On physical examination, the abdomen is distended. Examination of the anus reveals extrusion of the rectal mucosa through the external anal sphincter, and digital rectal examination produces an explosive expulsion of gas and stool. The abdominal radiograph shows bowel distention and absence of distal gas. What is the most likely cause?

Question: What is the most likely cause?

Answer: Hirschsprung disease


Context: A 44-year-old man comes to the physician for a pre-employment evaluation. On questioning, he reports a mild cough, sore throat, and occasional headaches for 1 week. He has not had fever or weight loss. Nine years ago, he was diagnosed with HIV. He has gastroesophageal reflux disease. He has a history of IV drug abuse but quit 8 years ago. He has smoked one pack of cigarettes daily for 27 years and does not drink alcohol. Current medications include tenofovir, emtricitabine, efavirenz, and esomeprazole. He is 180 cm (5 ft 11 in) tall and weighs 89 kg (196 lbs); BMI is 27.5 kg/m2. His temperature is 37.3°C (99.1°F), pulse is 81/min, respirations are 17/min, and blood pressure is 145/75 mm Hg. Pulmonary examination shows no abnormalities. There are a few scattered old scars along the left elbow flexure. Laboratory studies show a leukocyte count of 6200/mm3, hemoglobin of 13.8 g/dL, and CD4+ count of 700/m3 (N = ≥ 500/mm3). A tuberculin skin test (TST) comes back after 50 hours with an induration of 3 mm in diameter. Which of the following is the most appropriate next step in management?

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

Answer: Reassurance


Context: A 40-year-old chronic smoker presents to the office complaining of a cough and pleuritic chest pain. He also has had pain in his right shoulder for the past 2 weeks. He denies fever, night sweats, but has noticed a 2.2 kg (5 lb) weight loss in the last month. He has no recent history of travel. Past medical history is unremarkable. On cardiopulmonary examination, bilateral velcro-like crackles are auscultated in the upper to middle lung fields, with normal heart sounds. There is a 3 x 3 cm swelling on the right shoulder with a normal range of motion and intact sensation. 5/5 muscular strength in all extremities is noted. Chest X-ray reveals bilateral nodular opacities in the upper lung lobes and a lytic lesion on the right humeral head. Electron microscopy of the lung biopsy shows the following. Which of the following is the most likely diagnosis?

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

Answer: Histiocytosis X


Context: A 2-week-old boy has developed bilious vomiting. He was born via cesarean section at term. On physical exam, his pulse is 140, blood pressure is 80/50 mmHg, and respirations are 40/min. His abdomen appears distended and appears diffusely tender to palpation. Abdominal imaging is obtained (Figures A). Which of the following describes the mechanism that caused this child's disorder?

Question: Which of the following describes the mechanism that caused this child's disorder?

Answer: Abnormal rotation of the midgut


Context:
A 57-year-old man comes to the emergency department because of pain in the sides of his abdomen and blood-tinged urine since the previous night. Over the last 2 days, he has also had progressive malaise, myalgia, and a generalized itchy rash. He has a history of gastroesophageal reflux that did not respond to ranitidine but has improved since taking pantoprazole 2 months ago. He occasionally takes acetaminophen for back pain. His vital signs are within normal limits. Examination shows a generalized, diffuse maculopapular rash. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 13 g/dL
Leukocyte count 7,800/mm3
Serum
Na+ 140 mEq/L
Cl- 105 mEq/L
K+ 4.6 mEq/L
HCO3- 25 mEq/L
Glucose 102 mg/dL
Creatinine 4.1 mg/dL
Renal ultrasonography shows no abnormalities. Which of the following findings is most likely to be observed in this patient?"

Question: Which of the following findings is most likely to be observed in this patient?"

Answer: Elevated levels of eosinophils in urine


Context:
A 46-year-old man is brought to the emergency department because of severe epigastric pain and vomiting for the past 4 hours. The pain is constant, radiates to his back, and is worse on lying down. He has had 3–4 episodes of greenish-colored vomit. He was treated for H. pylori infection around 2 months ago with triple-regimen therapy. He has atrial fibrillation and hypertension. He owns a distillery on the outskirts of a town. The patient drinks 4–5 alcoholic beverages daily. Current medications include dabigatran and metoprolol. He appears uncomfortable. His temperature is 37.8°C (100°F), pulse is 102/min, and blood pressure is 138/86 mm Hg. Examination shows severe epigastric tenderness to palpation with guarding but no rebound. Bowel sounds are hypoactive. Rectal examination shows no abnormalities. Laboratory studies show:
Hematocrit 53%
Leukocyte count 11,300/mm3
Serum
Na+ 133 mEq/L
Cl- 98 mEq/L
K+ 3.1 mEq/L
Calcium 7.8 mg/dL
Urea nitrogen 43 mg/dL
Glucose 271 mg/dL
Creatinine 2.0 mg/dL
Total bilirubin 0.7 mg/dL
Alkaline phosphatase 61 U/L
AST 19 U/L
ALT 17 U/L
γ-glutamyl transferase (GGT) 88 u/L (N=5–50 U/L)
Lipase 900 U/L (N=14–280 U/L)
Which of the following is the most appropriate next step in management?"

Question:
Laboratory studies show:
Hematocrit 53%
Leukocyte count 11,300/mm3
Serum
Na+ 133 mEq/L
Cl- 98 mEq/L
K+ 3.1 mEq/L
Calcium 7.8 mg/dL
Urea nitrogen 43 mg/dL
Glucose 271 mg/dL
Creatinine 2.0 mg/dL
Total bilirubin 0.7 mg/dL
Alkaline phosphatase 61 U/L
AST 19 U/L
ALT 17 U/L
γ-glutamyl transferase (GGT) 88 u/L (N=5–50 U/L)
Lipase 900 U/L (N=14–280 U/L)
Which of the following is the most appropriate next step in management?"

Answer:
Crystalloid fluid infusion
"


Context: A 45-year-old woman presents with severe, acute-onset colicky abdominal pain and nausea. She also describes bone pain, constipation, headache, decreased vision, and menstrual irregularity. Past medical history is significant for surgical removal of an insulinoma one year ago. Two months ago, she was prescribed fluoxetine for depression but hasn’t found it very helpful. Family history is significant for a rare genetic syndrome. Non-contrast CT, CBC, CMP, and urinalysis are ordered in the diagnostic work-up. Urine sediment is significant for the findings shown in the picture. Which of the following will also be a likely significant finding in the diagnostic workup?

Question: Which of the following will also be a likely significant finding in the diagnostic workup?

Answer: Decreased urine pH


Context: A 38-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the physician because of a 1-day history of dyspnea and left-sided chest pain that is worse when she breathes deeply. One week ago, she returned from a trip to Chile, where she had a 3-day episode of flu-like symptoms that resolved without treatment. Pregnancy and delivery of her first child were uncomplicated. She has no history of serious illness. Her temperature is 37.2°C (99°F), pulse is 118/min, respirations are 28/min and slightly labored, and blood pressure is 110/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. Examination shows jugular venous distention and bilateral pitting edema below the knees that is worse on the left-side. There is decreased breath sounds over the left lung base. The uterus is consistent in size with a 32-week gestation. The remainder of the examination shows no abnormalities. Further evaluation of this patient is most likely to show which of the following findings?

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

Answer: Noncompressible femoral vein on ultrasonography


Context: A 43-year-old gentleman with a history of intravenous drug use presents with general fatigue and weakness accompanied by swelling in his ankles and lower legs. Further questions elicit that he has had many infections due to his drug use but has not previously had any cardiac or pulmonary issues. Upon physical examination you notice a holosystolic blowing murmur radiating to the right sternal border, which the patient denies being told about previously. Based on this presentation, what is the most likely cause of the murmur?

Question: Based on this presentation, what is the most likely cause of the murmur?

Answer: Tricuspid regurgitation


Context: A 34 year-old-male with a previous diagnosis of Grave’s disease presents for a check-up. Since his diagnosis 4 months ago, the patient’s symptoms have been relatively well-controlled with medications since starting them 3 weeks ago after an initial unsuccessful course of radioiodine ablation. The patient’s complete blood count reveals decreased absolute neutrophils at 450/mL and a slightly decreased hematocrit of 39%. Which of the following is the most likely cause of this patient’s abnormal laboratory results?

Question: Which of the following is the most likely cause of this patient’s abnormal laboratory results?

Answer: Methimazole


Context:
A 60-year-old male presents to the emergency room with shortness of breath after waking up in the middle of the night with a "choking" sensation. The patient has a history of hypertension and MI. Physical examination reveals bibasilar inspiratory crackles and an S3 heart sound.

Which of the following drugs should be administered for rapid, significant relief of this patient's symptoms?

Question: Which of the following drugs should be administered for rapid, significant relief of this patient's symptoms?

Answer: A drug that acts on the Na/K/Cl symporter in the thick ascending limb of the loop of Henle


Context: An autopsy of a patient's heart who recently died in a motor vehicle accident shows multiple nodules near the line of closure on the ventricular side of the mitral valve leaflet. Microscopic examination shows that these nodules are composed of immune complexes, mononuclear cells, and thrombi interwoven with fibrin strands. These nodules are most likely to be found in which of the following patients?

Question: These nodules are most likely to be found in which of the following patients?

Answer: A 41-year-old female with a facial rash and nonerosive arthritis


Context: A 50-year-old man presents with headache, chest discomfort, and blurred vision. His headache started 2 days ago and has not improved. He describes it as severe, throbbing, localized to the occipital part of the head and worse at the end of the day. He says he has associated nausea but denies any vomiting. Past medical history is significant for hypertension diagnosed 15 years ago, managed with beta-blockers until the patient self d/c’ed them a month ago. He has not seen a physician for the past 2 years. Family history is significant for hypertension and an ST-elevation myocardial infarction in his father and diabetes mellitus in his mother. Vitals signs are a blood pressure of 200/110 mm Hg, a pulse rate of 100/min and respiratory rate of 18/min Ophthalmoscopy reveals arteriolar nicking and papilledema. His ECG is normal. Laboratory findings are significant for a serum creatinine of 1.4 mg/dL and a blood urea nitrogen of 25 mg/dL. Urinalysis has 2+ protein.  He is started on intravenous nitroprusside. Which of the following best explains the pathophysiology responsible for the neovascular changes present in this patient?

Question: Which of the following best explains the pathophysiology responsible for the neovascular changes present in this patient?

Answer: Smooth muscle hyperplasia and duplication of the basement membrane


Context: Forty minutes after undergoing nasal polypectomy for refractory rhinitis, a 48-year-old woman develops chest tightness and shortness of breath. The surgical course was uncomplicated and the patient was successfully extubated. She received ketorolac for postoperative pain. She has a history of asthma, hypertension, and aspirin allergy. Her daily medications include metoprolol and lisinopril. Examination shows a flushed face. Chest auscultation reveals wheezes and decreased breath sounds in both lung fields. An ECG shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?

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

Answer: Pseudoallergic reaction


Context: A 51-year-old man presents to his physician’s office with a persistent fever that started a week ago. He says that his temperature ranges between 37.8–39.1°C (100–102.5°F). He has also had a persistent cough productive of foul-smelling sputum. There is no significant medical history to report, but he does mention that he has been suffering from dental caries for the last month. He has been meaning to see his dentist but has been too busy to do so. His blood pressure is 120/70 mm Hg, the respirations are 18/min, and the temperature is 38.5°C (101.3°F). His oxygen saturation is 90% on room air. On examination, he has decreased breath sounds in his right lung field with the presence of soft inspiratory crackles. He is sent to the laboratory for sputum analysis and chest imaging. Based on his history and physical examination, which of the following would be the next best step in the management of this patient?

Question: Based on his history and physical examination, which of the following would be the next best step in the management of this patient?

Answer: Clindamycin


Context: An 11-year-old boy is brought to the emergency department because he was found to have severe abdominal pain and vomiting in school. On presentation, he is found to be lethargic and difficult to arouse. His parents noticed that he was eating and drinking more over the last month; however, they attributed the changes to entering a growth spurt. Physical exam reveals deep and rapid breathing as well as an fruity odor on his breath. Which of the following sets of labs would most likely be seen in this patient?

Question: Which of the following sets of labs would most likely be seen in this patient?

Answer: E


Context: A 55-year-old man comes to the physician because of a 6-month history of cough, breathlessness, and fatigue. He has also had an 8-kg (17.6-lb) weight loss and night sweats during this time. He appears pale. His vital signs are within normal limits. Physical examination shows hepatosplenomegaly. His leukocyte count is 78,000/mm3. A peripheral blood smear shows > 80% neutrophils with band forms and immature and mature neutrophil precursors. A bone marrow biopsy shows hyperplasia with proliferation of all myeloid elements, and an increased leukocyte alkaline phosphatase activity. An x-ray of the chest shows an 8-mm nodule adjacent to the right lung hilum. Which of the following is the most likely cause of this patient's laboratory findings?

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

Answer: Leukemoid reaction


Context:
A 46-year-old woman comes to the clinic complaining of right eye irritation. The eye is itchy and red. Discomfort has been relatively constant for the last 6 months, and nothing makes it better or worse. Past medical history is significant for hypertension, hyperlipidemia, and aggressive tooth decay, requiring several root canals and the removal and replacement of several teeth. She takes chlorthalidone, fluvastatin, and daily ibuprofen for tooth pain. She has smoked a pack of cigarettes daily since the age of 20 and drinks alcohol on the weekends. She does not use illicit drugs. She cannot provide any family history as she was adopted. Her temperature is 36.7°C (98°F), blood pressure is 135/65 mm Hg, pulse is 82/min, respiratory rate is 15/min, and BMI is 27 kg/m2. A thorough eye exam is performed and shows no foreign objects. Both eyes appear erythematous and infected. Schirmer test is abnormal.
Laboratory test
Complete blood count:
Hemoglobin    9.5 g/dL
Leukocytes 12,500/mm3
Platelets 155,000/mm3
ESR   60 mm/hr
Antinuclear antibody Positive
What is the best next step in the management of this patient?

Question:
Laboratory test
Complete blood count:
Hemoglobin    9.5 g/dL
Leukocytes 12,500/mm3
Platelets 155,000/mm3
ESR   60 mm/hr
Antinuclear antibody Positive
What is the best next step in the management of this patient?

Answer: Artificial tears


Context: A 20-year-old man presents to your office with dyspnea, reporting nocturnal cough. You note expiratory wheezing on auscultation. Chest x-ray reveals increased anteroposterior diameter. Past medical history is significant for multiple episodes of "bronchitis" as a child. Which of the following drugs would be most effective for long-term treatment of this patient?

Question: Which of the following drugs would be most effective for long-term treatment of this patient?

Answer: Fluticasone


Context: A 75-year-old woman presents complaining of severe shortness of breath and peripheral edema. Her family reports that she has gained a significant amount of weight within the past week. Despite considerable efforts in the emergency department and ICU, she dies from sudden cardiac death overnight. The family requests an autopsy to determine her cause of death. Amongst other studies, a biopsy of her liver is shown. What was the most likely cause of the liver changes shown?

Question: What was the most likely cause of the liver changes shown?

Answer: Congestive heart failure


Context: A 13-year-old girl is brought to the physician because of an itchy rash on her knee and elbow creases. She has had this rash since early childhood. Physical examination of the affected skin shows crusty erythematous papules with skin thickening. She is prescribed topical pimecrolimus. The beneficial effect of this drug is best explained by inhibition of which of the following processes?

Question: The beneficial effect of this drug is best explained by inhibition of which of the following processes?

Answer: Dephosphorylation of serine


Context:
A 46-year-old man comes to the physician for a follow-up examination. Two weeks ago, he underwent laparoscopic herniorrhaphy for an indirect inguinal hernia. During the procedure, a black liver was noted. He has a history of intermittent scleral icterus that resolved without treatment. Serum studies show:
Aspartate aminotransferase 30 IU/L
Alanine aminotransferase 35 IU/L
Alkaline phosphatase 47 mg/dL
Total bilirubin 1.7 mg/dL
Direct bilirubin 1.1 mg/dL
Which of the following is the most likely diagnosis?"

Question:
Serum studies show:
Aspartate aminotransferase 30 IU/L
Alanine aminotransferase 35 IU/L
Alkaline phosphatase 47 mg/dL
Total bilirubin 1.7 mg/dL
Direct bilirubin 1.1 mg/dL
Which of the following is the most likely diagnosis?"

Answer: Dubin-Johnson syndrome


Context: A 40-year-old woman comes to the physician because of a 6-day history of painless blisters on her hands, forearms, and face. Some of the blisters have popped and released a clear fluid. She is otherwise healthy. She had been working the night shift as a security guard for the past few years and switched to the day shift 2 weeks ago. She started wearing a new metal wristwatch last week. Her mother had a similar rash in the past. Her only medication is an estrogen-based oral contraceptive. She drinks 2 beers every night and occasionally more on the weekends. She used intravenous heroin in the past but stopped 20 years ago. Vital signs are within normal limits. Examination shows bullae and oozing erosions in different stages of healing on her arms, dorsal hands, ears, and face. Oral examination shows no abnormalities. There are some atrophic white scars and patches of hyperpigmented skin on the arms and face. Further evaluation of this patient is most likely to show which of the following findings?

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

Answer: Increased urinary uroporphyrin


Context: A 2-month-old boy is brought to the emergency room by his mother who reports he has appeared lethargic for the past 3 hours. She reports that she left the patient with a new nanny this morning, and he was behaving normally. When she got home in the afternoon, the patient seemed lethargic and would not breastfeed as usual. At birth, the child had an Apgar score of 8/9 and weighed 2.8 kg (6.1 lb). Growth has been in the 90th percentile, and the patient has been meeting all developmental milestones. There is no significant past medical history, and vaccinations are up-to-date. On physical examination, the patient does not seem arousable. Ophthalmologic examination shows retinal hemorrhages. Which of the following findings would most likely be expected on a noncontrast CT scan of the head?

Question: Which of the following findings would most likely be expected on a noncontrast CT scan of the head?

Answer: Crescent-shaped hematoma


Context: A 42-year-old man comes to his primary care physician complaining of abdominal pain. He describes intermittent, burning, epigastric pain over the past 4 months. He reports that the pain worsens following meals. He had an upper gastrointestinal endoscopy done 2 months ago that showed a gastric ulcer without evidence of malignancy. The patient was prescribed pantoprazole with minimal improvement in symptoms. He denies nausea, vomiting, diarrhea, or melena. The patient has no other medical problems. He had a total knee replacement 3 years ago following a motor vehicle accident for which he took naproxen for 2 months for pain management. He has smoked 1 pack per day since the age 22 and drinks 1-2 beers several nights a week with dinner. He works as a truck driver, and his diet consists of mostly of fast food. His family history is notable for hypertension in his paternal grandfather and coronary artery disease in his mother. On physical examination, the abdomen is soft, nondistended, and mildly tender in the mid-epigastric region. A stool test is positive for Helicobacter pylori antigen. In addition to antibiotic therapy, which of the following is the most likely to decrease the recurrence of the patient’s symptoms?

Question: In addition to antibiotic therapy, which of the following is the most likely to decrease the recurrence of the patient’s symptoms?

Answer: Smoking cessation


Context: An newborn infant comes to the attention of the neonatal care unit because he started having heavy and rapid breathing. In addition, he was found to be very irritable with pale skin and profuse sweating. Finally, he was found to have cold feet with diminished lower extremity pulses. Cardiac auscultation reveals a harsh systolic murmur along the left sternal border. Notably, the patient is not observed to have cyanosis. Which of the following treatments would most likely be effective for this patient's condition?

Question: Which of the following treatments would most likely be effective for this patient's condition?

Answer: Prostaglandin E1


Context: A 50-year-old man with a history of stage 4 kidney disease was admitted to the hospital for an elective hemicolectomy. His past medical history is significant for severe diverticulitis. After the procedure he becomes septic and was placed on broad spectrum antibiotics. On morning rounds, he appear weak and complains of fatigue and nausea. His words are soft and he has difficulty answering questions. His temperature is 38.9°C (102.1°C), heart rate is 110/min, respiratory rate is 15/min, blood pressure 90/65 mm Hg, and saturation is 89% on room air. On physical exam, his mental status appears altered. He has a bruise on his left arm that spontaneously appeared overnight. His cardiac exam is positive for a weak friction rub. Blood specimens are collected and sent for evaluation. An ECG is performed (see image). What therapy will this patient most likely receive next?

Question: What therapy will this patient most likely receive next?

Answer: Send the patient for hemodialysis


Context: A 56-year-old man comes to the physician for increasing shortness of breath and retrosternal chest pain on exertion. He has smoked 2 packs of cigarettes daily for 35 years. His blood pressure is 145/90 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this patient's auscultation findings?

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

Answer: Left ventricular failure


Context:
A 59-year-old man presents with fatigue and tingling in both feet and hands. Past medical history is significant for type 2 diabetes mellitus diagnosed 27 years ago, for which he takes metformin and gliclazide. He denies any smoking, alcohol, or illicit drug use. Physical examination is unremarkable. Laboratory results reveal the following:
Hemoglobin 10.4 g/dL
Hematocrit 31%
Mean corpuscular volume 110 μm3
Corrected reticulocyte index low
Leukocyte count 7,500 /mm3
Platelet count 250,000 /mm3
A peripheral blood smear is shown in the exhibit (see image). Which of the following best describes the underlying cause of this patient’s anemia?

Question: Which of the following best describes the underlying cause of this patient’s anemia?

Answer: Impaired DNA synthesis of red cells


Context: A 19-year-old man presents to his primary care physician for evaluation before going off to college. Specifically, he wants to know how to stay healthy while living outside his home. Since childhood he has suffered severe sunburns even when he goes outside for a small period of time. He has also developed many freckles and rough-surfaced growths starting at the same age. Finally, his eyes are very sensitive and become irritated, bloodshot, and painful after being outside. A defect in a protein with which of the following functions is most likely responsible for this patient's symptoms?

Question: A defect in a protein with which of the following functions is most likely responsible for this patient's symptoms?

Answer: Recognition of chemically dimerized bases


Context: An 11-year-old boy presents to your clinic after 4 months of pain and swelling in his thigh. His mother states that at first she thought his condition was due to roughhousing, but it hasn’t gone away and now she’s concerned. You perform an X-ray that shows an ‘onion skin’ appearance on the diaphysis of the femur. You are concerned about a malignancy, so you perform a PET scan that reveals lung nodules. Which of the following is most associated with this disease?

Question: Which of the following is most associated with this disease?

Answer: t(11;22) translocation


Context: A 53-year-old woman presents to her physician for evaluation of sudden onset respiratory distress for the past few hours. The past medical history includes a myocardial infarction 2 years ago. The vital signs include a blood pressure 70/40 mm Hg, pulse 92/min, respiratory rate 28/min, and SpO2 92% on room air. The physical examination reveals bilateral basal crepitations on auscultation. The echocardiogram reveals an ejection fraction of 34%. She is admitted to the medical floor and started on furosemide. The urine output in 24 hours is 400 mL. The blood urea nitrogen is 45 mg/dL and the serum creatinine is 1.85 mg/dL. The fractional excretion of sodium is 0.89 %. Urinalysis revealed muddy brown granular casts. Which of the following is the most likely cause of the abnormal urinalysis?

Question: Which of the following is the most likely cause of the abnormal urinalysis?

Answer: Acute tubular necrosis


Context: A 34-year-old man presents to the neurology clinic for an appointment after having been referred by his family physician. Four months earlier, he presented with worsening upper limb weakness. His primary complaint at that time was that he was unable to play badminton because of increasing difficulty in moving his shoulders and arms. The weakness later progressed, and he now has spontaneous twitching of his leg and thigh muscles throughout the day. He also feels increasingly fatigued. On physical examination, there is significant atrophy of his arm and thigh muscles. Cranial nerves testing is unremarkable. The pupillary light and accommodation reflexes are both normal. Swallowing, speech, and eye movements are all normal. His cousin had similar symptoms at the age of 19 years old. Which of the following is most likely to also be seen in this patient?

Question: Which of the following is most likely to also be seen in this patient?

Answer: Spastic paralysis


Context: A 27-year-old woman with cystic fibrosis comes to the physician for a follow-up examination. She has been hospitalized frequently for pneumonia and nephrolithiasis and is on chronic antibiotic therapy for recurrent sinusitis. The patient and her husband would like to have a child but have been unable to conceive. She feels that she can never achieve a full and happy life due to her disease and says that she is “totally frustrated” with the barriers of her illness. Although her family is supportive, she doesn't want to feel like a burden and tries to shield them from her struggles. Which of the following is the most appropriate statement by the physician?

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

Answer: """I understand that living with cystic fibrosis is not easy. You are not alone in this. I would like to recommend a support group."""


Context: A 34-year-old male visits the clinic with complaints of intermittent diarrhea over the past 6 months. He has lost 6.8 kg (15 lb) over that time period. His frequent bowel movements are affecting his social life and he would like definitive treatment. Past medical history is significant for chronic type 2 diabetes that is well controlled with insulin. No other family member has a similar condition. He does not smoke tobacco and drinks alcohol only on weekends. Today, his vitals are within normal limits. On physical exam, he appears gaunt and anxious. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Additionally, the patient has a red-purple rash on his lower abdomen, groin, and the dorsum of both hands. The rash consists of pruritic annular lesions. He is referred to a dermatologist for core biopsy which is consistent with necrolytic migratory erythema. Further workup reveals a large hormone secreting mass in the tail of his pancreas. Which of the following is the action of the hormone that is in excess in this patient?

Question: Which of the following is the action of the hormone that is in excess in this patient?

Answer: Stimulation of lipolysis


Context: A 15-year-old girl is brought to the clinic by her mother for an annual well-exam. She is relatively healthy with an unremarkable birth history. She reports no specific concerns except for the fact that her friends “already got their periods and I still haven’t gotten mine.” Her mom reports that she also had her menarche late and told her not to worry. When alone, the patient denies any pain, fevers, weight changes, vaginal discharge, or psychosocial stressors. Physical examination demonstrates a healthy female with a Tanner 4 stage of development of breast, genitalia, and pubic hair. What findings would you expect in this patient?

Question: What findings would you expect in this patient?

Answer: Raised areola


Context: A 55-year-old man with long-standing diabetes presents with a fragility fracture. He has chronic renal failure secondary to his diabetes. His serum parathyroid hormone concentration is elevated. You measure his serum concentration of 25(OH)-vitamin D and find it to be normal, but his concentration of 1,25(OH)-vitamin D is decreased. Which of the following represents a correct pairing of his clinical condition and serum calcium level?

Question: Which of the following represents a correct pairing of his clinical condition and serum calcium level?

Answer: Secondary hyperparathyroidism with low serum calcium


Context: A 47-year-old man with bipolar I disorder and hypertension comes to the physician because of a 2-week history of increased thirst, urinary frequency, and sleep disturbance. He says that he now drinks up to 30 cups of water daily. He has smoked 2 packs of cigarettes daily for the past 20 years. Examination shows decreased skin turgor. Serum studies show a sodium concentration of 149 mEq/L, a potassium concentration of 4.1 mEq/L, and an elevated antidiuretic hormone concentration. His urine osmolality is 121 mOsm/kg H2O. Which of the following is the most likely explanation for these findings?

Question: Which of the following is the most likely explanation for these findings?

Answer: Adverse effect of a medication


Context: A 23-year-old man comes to his primary care provider after having severe abdominal cramping and diarrhea beginning the previous night. He denies any fevers or vomiting. Of note, he reports that he works in a nursing home and that several residents of the nursing home exhibited similar symptoms this morning. On exam, his temperature is 99.7°F (37.6°C), blood pressure is 116/80 mmHg, pulse is 88/min, and respirations are 13/min. His stool is cultured on blood agar and it is notable for a double zone of hemolysis. Which of the following organisms is the most likely cause?

Question: Which of the following organisms is the most likely cause?

Answer: Clostridium perfringens