Context: A 62-year-old man presents to his primary care provider complaining of leg pain with exertion for the past 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse in his right calf than in his left, and it goes away when he stops walking. He has also noticed that his symptoms are progressing and that this pain is occurring sooner than before. His medical history is remarkable for type 2 diabetes mellitus and 30-pack-year smoking history. His ankle-brachial index (ABI) is found to be 0.80. Which of the following can be used as initial therapy for this patient's condition?

Question: Which of the following can be used as initial therapy for this patient's condition?

Answer: Cilostazol


Context: A 59-year-old man presents to the health clinic for evaluation of severe itching for the past week. The itching is worse at night while lying in bed. The patient has a past medical history of hyperlipidemia, atrial fibrillation, and colon cancer. The patient takes rivaroxaban, simvastatin, and aspirin. The patient has a surgical history of colon resection, appendectomy, and tonsillectomy. He drinks a 6-pack of beer almost every night of the week. He smokes 2 packs of cigarettes daily and has been living at a homeless shelter for the past 6 months. Examination of the skin shows small crusted sores and superficial, wavy gray lines along the wrists and interdigital spaces of both hands as seen in the image. Small vesicles are also present along with excoriations. Which of the following is the most appropriate treatment option for this patient?

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

Answer: Permethrin


Context: A 26-year-old G1P0 woman is brought to the emergency room by her spouse for persistently erratic behavior. Her spouse reports that she has been sleeping > 1 hour a night, and it sometimes seems like she’s talking to herself. She has maxed out their credit cards on baby clothes. The patient’s spouse reports this has been going on for over a month. Since first seeing a physician, she has been prescribed multiple first and second generation antipsychotics, but the patient’s spouse reports that her behavior has failed to improve. Upon examination, the patient is speaking rapidly and occasionally gets up to pace the room. She reports she is doing “amazing,” and that she is “so excited for the baby to get here because I’m going to be the best mom.” She denies illicit drug use, audiovisual hallucinations, or suicidal ideation. The attending psychiatrist prescribes a class of medication the patient has not yet tried to treat the patient’s psychiatric condition. In terms of this new medication, which of the following is the patient’s newborn most likely at increased risk for?

Question: In terms of this new medication, which of the following is the patient’s newborn most likely at increased risk for?

Answer: Right ventricular atrialization


Context: A 45-year-old woman presents to her primary care physician for knee pain. She states that she has been experiencing a discomfort and pain in her left knee that lasts for several hours but tends to improve with use. She takes ibuprofen occasionally which has been minimally helpful. She states that this pain is making it difficult for her to work as a cashier. Her temperature is 98.6°F (37.0°C), blood pressure is 117/58 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 97% on room air. Physical exam reveals a stable gait that the patient claims causes her pain. The patient has a non-pulsatile, non-erythematous, palpable mass over the posterior aspect of her left knee that is roughly 3 to 4 cm in diameter and is hypoechoic on ultrasound. Which of the following is associated with this patient's condition?

Question: Which of the following is associated with this patient's condition?

Answer: Type IV hypersensitivity


Context: One day after undergoing total knee replacement for advanced degenerative osteoarthritis, a 66-year-old man has progressive lower abdominal pain. The surgery was performed under general anesthesia and the patient was temporarily catheterized for perioperative fluid balance. Several hours after the surgery, the patient began to have decreasing voiding volumes, nausea, and progressive, dull lower abdominal pain. He has Sjögren syndrome. He is sexually active with his wife and one other woman and uses condoms inconsistently. He does not smoke and drinks beer occasionally. Current medications include pilocarpine eye drops. He appears uncomfortable and is diaphoretic. His temperature is 37.3°C (99.1°F), pulse is 90/min, and blood pressure is 130/82 mm Hg. Abdominal examination shows a pelvic mass extending to the umbilicus. It is dull on percussion and diffusely tender to palpation. His hemoglobin concentration is 13.9 g/dL, leukocyte count is 9,000/mm3, a platelet count is 230,000/mm3. An attempt to recatheterize the patient transurethrally is unsuccessful. 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: Benign prostatic enlargement


Context: A 25-day-old male infant presents to the emergency department because his mother states that he has been acting irritable for the past 2 days and has now developed a fever. On exam, the infant appears uncomfortable and has a temperature of 39.1 C. IV access is immediately obtained and a complete blood count and blood cultures are drawn. Lumbar puncture demonstrates an elevated opening pressure, elevated polymorphonuclear neutrophil, elevated protein, and decreased glucose. Ampicillin and cefotaxime are immediately initiated and CSF culture eventually demonstrates infection with a Gram-negative rod. Which of the following properties of this organism was necessary for the infection of this infant?

Question: Which of the following properties of this organism was necessary for the infection of this infant?

Answer: K capsule


Context: A 23-year-old primigravida pregnant patient is in her 3rd trimester with twins. She complains of itching and skin lesions. The examination shows vesicular skin lesions on the abdomen but not on the face, palms, or soles. A picture of her abdomen is shown in the image. Her past medical history is insignificant. Her vital signs are all within normal limits. What is the next best step in management?

Question: What is the next best step in management?

Answer: Reassure her and provide symptomatic relief with topical steroids


Context: A 67-year-old man is brought to the physician by his daughter because he frequently misplaces his personal belongings and becomes easily confused. His daughter mentions that his symptoms have progressively worsened for the past one year. On mental status examination, he is oriented to person, place, and time. He vividly recalls memories from his childhood but can only recall one of three objects presented to him after 5 minutes. His affect is normal. This patients' symptoms are most likely caused by damage to which of the following?

Question: This patients' symptoms are most likely caused by damage to which of the following?

Answer: Hippocampus


Context: A 59-year-old woman comes to the physician because of a 1-year history of pain and stiffness in her fingers and knees. The stiffness lasts for about 10 minutes after she wakes up in the morning. She also reports that her knee pain is worse in the evening. She drinks one glass of wine daily. Her only medication is acetaminophen. She is 175 cm (5 ft 9 in) tall and weighs 102 kg (225 lb); BMI is 33 kg/m2. Physical examination shows firm nodules on the distal interphalangeal joints of the index, ring, and little fingers of both hands. Which of the following is the most likely diagnosis?

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

Answer: Osteoarthritis


Context: A 23-year-old man is brought to the emergency department from a college party because of a 1-hour history of a crawling sensation under his skin. He appears anxious and is markedly pale. His temperature is 38°C (100.4°F), pulse is 104/min, respirations are 18/min, and blood pressure is 145/90 mm Hg. Physical examination shows diaphoretic skin, moist mucous membranes, and dilated pupils. Which of the following substances is most likely the cause of this patient's symptoms?

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

Answer: Cocaine


Context: A 68-year old woman presents with recurring headaches and pain while combing her hair. Her past medical history is significant for hypertension, glaucoma and chronic deep vein thrombosis in her right leg. Current medication includes rivaroxaban, latanoprost, and benazepril. Her vitals include: blood pressure 130/82 mm Hg, pulse 74/min, respiratory rate 14/min, temperature 36.6℃ (97.9℉). Physical examination reveals neck stiffness and difficulty standing up due to pain in the lower limbs. Strength is 5 out of 5 in the upper and lower extremities bilaterally. Which of the following is the next best step in the management of this patient?

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

Answer: Erythrocyte sedimentation rate


Context: A 13-year-old boy with recently diagnosed schizophrenia presents with feelings of anxiety. The patient says that he has been having feelings of dread, especially since a friend of his has been getting bullied at school. He feels troubled by these feeling almost every day and makes it difficult for him to get ready to go to school. He also has been hallucinating worse lately. Past medical history is significant for schizophrenia diagnosed 1 year ago. Current medications are fluphenazine. The patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Which of the following medications would most likely be a better course of treatment for this patient?

Question: Which of the following medications would most likely be a better course of treatment for this patient?

Answer: Ziprasidone


Context: A 39-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the emergency department 1 hour after the sudden onset of severe abdominal pain and nausea. She has had one episode of nonbloody vomiting. Pregnancy has been uncomplicated, except for a blood pressure measurement of 150/90 mm Hg on her last prenatal visit. Her first child was delivered vaginally; her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. She appears anxious and pale. Her temperature is 36.1°C (96°F), pulse is 115/min, and blood pressure is 92/65 mm Hg. Extremities are cool and clammy. Pelvic examination shows a rigid, tender uterus. The cervix is 30% effaced and 1 cm dilated; the vertex is at -1 station. The fetal heart rate is 100/min. Which of the following is the most likely diagnosis?

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

Answer: Abruptio placentae


Context: A 24-year-old professional soccer player presents to the clinic with discomfort and pain while walking. He says that he has an unstable knee joint that started after an injury during a match last week. He adds that he heard a popping sound at the time of the injury. Physical examination of the knee reveals swelling of the knee joint with a positive anterior drawer test. Which of the following structures is most likely damaged in this patient?

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

Answer: Anterior cruciate ligament


Context: A 42-year-old woman comes to the physician with acute, severe pain in the middle of her lower back. She also complains of constipation and trouble sleeping recently. Menses occur regularly at 28-day intervals. Examination shows localized tenderness to palpation over the lumbar spine. Serum calcium is 14 mg/dL and serum phosphorus is 1.5 mg/dL. An x-ray of the lumbar spine shows a compression fracture of the L4 vertebral body and osteopenia. Which of the following is the most likely underlying cause of this patient's decreased bone mineral density?

Question: Which of the following is the most likely underlying cause of this patient's decreased bone mineral density?

Answer: Increase in interleukin-1 secretion


Context:
A 55-year-old man with a history of hypertension and benign prostate hyperplasia presents for follow-up 4 days into the treatment of a urinary tract infection with trimethoprim-sulfamethoxazole. His symptoms have resolved, and he reports no problems with urination, with the exception of a weak urine stream and hesitancy, which he has had for the past 2 years. At the time of this visit, the patient is afebrile; the blood pressure is 130/88 mm Hg and the heart rate is 80/min. There is no flank tenderness. A urinalysis reveals no leukocytes and is negative for esterase. The urinalysis reveals 2 red blood cells (RBCs)/ high power field (HPF), and there are no casts on urinary sediment analysis. The physician, however, notices the following abnormality:
Prior treatment
BUN 12 mg/dL
Creatinine 1.2 mg/dL
Today’s visit
BUN 13 mg/dL
Creatinine 2.1 mg/dL

Question:
The physician, however, notices the following abnormality:
Prior treatment
BUN 12 mg/dL
Creatinine 1.2 mg/dL
Today’s visit
BUN 13 mg/dL
Creatinine 2.1 mg/dL

Answer: Reassure the patient, stop trimethoprim-sulfamethoxazole and repeat the measurement in 1–2 weeks


Context: An 18-year-old female presents to the clinic complaining of acute abdominal pain for the past couple of hours. The pain is concentrated at the right lower quadrant (RLQ) with no clear precipitating factor and is worse with movement. Acetaminophen seems to help a little but she is concerned as the pain has occurred monthly for the past 3 months. She denies any headache, chest pain, weight changes, diarrhea, nausea/vomiting, fever, or sexual activity. The patient reports a regular menstruation cycle with her last period being 2 weeks ago. A physical examination demonstrates a RLQ that is tender to palpation with a negative psoas sign. A urine beta-hCG test is negative. An ultrasound of the abdomen is unremarkable. What is the main function of the hormone that is primarily responsible for this patient’s symptoms?

Question: What is the main function of the hormone that is primarily responsible for this patient’s symptoms?

Answer: Increases the activity of cholesterol desmolase to synthesize progesterone


Context: A 5-year-old boy is brought to the emergency department by his stepmother because of multiple injuries. She says that he sustained these injuries while playing. Radiographic findings show multiple fractures in various stages of healing. Physical examination shows the findings in the image below. What is the most likely diagnosis in this patient?

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

Answer: Osteogenesis imperfecta


Context: A 5-year-old boy is brought to the physician by his mother because he does not “listen to her” anymore. The mother also reports that her son cannot concentrate on any tasks lasting longer than just a few minutes. Teachers at his preschool report that the patient is more active compared to other preschoolers, frequently interrupts or bothers other children, and is very forgetful. Last year the patient was expelled from another preschool for hitting his teacher and his classmates when he did not get what he wanted and for being disruptive during classes. He was born at term via vaginal delivery and has been healthy except for 3 episodes of acute otitis media at the age of 2 years. He has met all developmental milestones. His mother has major depressive disorder and his father has Graves' disease. He appears healthy and well nourished. Examination shows that the patient does not seem to listen when spoken to directly. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in treatment?

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

Answer: Behavior therapy


Context: At a routine exam, a 68-year-old woman is discovered to have a serum calcium level of 11.5 mg/dL. Follow-up laboratory tests show a high parathyroid hormone with low phosphorus and mildly elevated alkaline phosphatase. 24-hour urine calcium level is elevated. Review of symptoms includes complaints of fatigue, constipation, and diffuse bone pain for which she takes vitamin D. Past medical history is significant for type 2 diabetes mellitus for 25 years and essential hypertension for 15 years. The patient has a history of kidney stones. Family history is irrelevant. Which of the following radiologic findings is consistent with the patient's condition?

Question: Which of the following radiologic findings is consistent with the patient's condition?

Answer: Subperiosteal bone resorption on hand X-ray


Context: A 29-year-old woman, gravida 1, para 0, at 36 weeks' gestation is brought to the emergency department after an episode of dizziness and vomiting followed by loss of consciousness lasting 1 minute. She reports that her symptoms started after lying down on her back to rest, as she felt tired during yoga class. Her pregnancy has been uncomplicated. On arrival, she is diaphoretic and pale. Her pulse is 115/min and blood pressure is 90/58 mm Hg. On examination, the patient is lying in the supine position with a fundal height of 36 cm. There is a prolonged fetal heart rate deceleration to 80/min. Which of the following is the most appropriate action to reverse this patient's symptoms in the future?

Question: Which of the following is the most appropriate action to reverse this patient's symptoms in the future?

Answer: Lying in the left lateral decubitus position


Context: A 32-year-old man presents to an outpatient clinic for tuberculosis prophylaxis before leaving for a trip to Asia, where tuberculosis is endemic. The Mantoux test is positive, but the chest X-ray and AFB sputum culture are negative. He was started on isoniazid. What is the most likely mechanism of resistance to isoniazid?

Question: What is the most likely mechanism of resistance to isoniazid?

Answer: Mutations in katG


Context: A 33-year-old man with recently diagnosed testicular cancer visits his oncologist to discuss the treatment plan. His left testicle was removed after a thorough workup of a lump. A pelvic CT showed no enlarged lymph nodes and a simple orchiectomy and pelvic lymph node dissection was completed. The final diagnosis was stage IB non-seminoma testicular cancer (pT2N0Mn/a). A combination of different chemotherapeutic medications is recommended including bleomycin, etoposide, and cisplatin. Each of the antineoplastic drugs has a different mechanism of action; each drug targets cancer cells at a specific phase in the cell cycle and works by inhibiting a major cellular process. Which of the following enzymes would be affected by bleomycin?

Question: Which of the following enzymes would be affected by bleomycin?

Answer: DNA polymerase β


Context: A 67-year-old woman presents to the clinic with a 9-month history of seeing bright red blood in the toilet after defecating. Additional complaints include fatigue, shortness of breath, and mild lethargy. She denies the loss of weight, abdominal pain, or changes in dietary behavior. She consumes a balanced diet and takes multiple vitamins every day. The current vital signs include the following: temperature is 37.0°C (98.6°F), pulse rate is 68/min, blood pressure is 130/81 mm Hg, and the respiratory rate is 13/min. On physical examination, you notice increased capillary refill time and pale mucosa. What are the most likely findings for hemoglobin, hematocrit, red blood cell count, and mean corpuscular volume?

Question: What are the most likely findings for hemoglobin, hematocrit, red blood cell count, and mean corpuscular volume?

Answer: Hemoglobin: ↓, hematocrit: ↓, red blood cell count: ↓, mean corpuscular volume: ↓


Context: A 20-year-old woman presents to student health for a 7-day history of sinus congestion. She has also had fever, sore throat, and infectious gastroenteritis. Upon further questioning, she has had similar problems 2 or 3 times a year for as long as she can remember. These have included sinus infections, ear infections, and lung infections. At the clinic, her temperature is 38.6°C (101.4°F), heart rate is 70/min, blood pressure is 126/78 mm Hg, respiratory rate is 18/min, and oxygen saturation is 98% on room air. Physical examination is notable for mucopurulent discharge from both nares and tenderness to palpation over her bilateral maxillae. Sputum gram stain shows gram-positive diplococci. Which of the following best describes the levels of immunoglobulins that would most likely be found upon testing this patient's serum?

Question: Which of the following best describes the levels of immunoglobulins that would most likely be found upon testing this patient's serum?

Answer: IgM Level: Normal, IgG Level: Normal, IgA Level: Low


Context: A 16-year-old girl is brought to the physician because menarche has not yet occurred. She has no history of serious illness and takes no medications. She is 162 cm (5 ft 3 in) tall and weighs 80 kg (176 lb); BMI is 31.2 kg/m2. Breast and pubic hair development is Tanner stage 4. She also has oily skin, acne, and hyperpigmentation of the intertriginous areas of her neck and axillae. The remainder of the examination, including pelvic examination, shows no abnormalities. Which of the following is the most likely explanation for this patient's amenorrhea?

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

Answer: Elevated LH:FSH ratio


Context: A 21-year-old man presents to the emergency department with acute back pain. The pain began a few hours prior to presentation and is located on the left lower back. The pain is described to be “shock-like,” 9/10 in pain severity, and radiates to the left groin. His temperature is 98.6°F (37°C), blood pressure is 120/75 mmHg, pulse is 101/min, and respirations are 18/min. The patient appears uncomfortable and is mildly diaphoretic. There is costovertebral angle tenderness and genitourinary exam is unremarkable. A non-contrast computerized tomography (CT) scan of the abdomen and pelvis demonstrates an opaque lesion affecting the left ureter with mild hydronephrosis. Straining of the urine with urine crystal analysis is demonstrated. Which of the following amino acids is most likely poorly reabsorbed by this patient’s kidney?

Question: Which of the following amino acids is most likely poorly reabsorbed by this patient’s kidney?

Answer: Lysine


Context: A 29-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the physician for a prenatal visit. Over the past two weeks, she has felt nauseous in the morning and has had vulvar pruritus and dysuria that started 5 days ago. Her first child was delivered by lower segment transverse cesarean section because of macrosomia from gestational diabetes. Her gestational diabetes resolved after the child was born. She appears well. Ultrasound confirms fetal heart tones and an intrauterine pregnancy. Speculum exam shows a whitish chunky discharge. Her vaginal pH is 4.2. A wet mount is performed and microscopic examination is shown. Which of the following is the most appropriate treatment?

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

Answer: Intravaginal clotrimazole


Context: A 31-year-old man is brought in to the clinic by his sister because she is concerned about his behavior since the death of their mother 2 months ago. The patient’s sister states that he has always been a ‘loner’ and preferred being by himself than socializing with others. His social isolation resulted in him being ‘socially awkward’, as described by his family. However, 2 months ago, when he found out about the death of their mother, he showed little emotion and attended her funeral in jeans and a dirty T-shirt which upset the rest of their family. When asked about it, he shrugged and said he was in a hurry to get to the funeral and “just left the house with what I had on.” He does not speak much during the interview, allowing his sister to speak on his behalf. His sister insists that he has ‘always been like this’, quiet and a complacent child who had no interest in playing with other children. The patient currently lives alone and spends his time repairing and building electrical appliances, and his sister is worried that his self-imposed isolation is making it ‘impossible for him to interact with other people normally’. Which of the following is the most likely diagnosis in this patient?

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

Answer: Schizoid personality disorder


Context: A male newborn is born at 37 weeks' gestation after spontaneous vaginal delivery. The mother had no prenatal care. Physical examination shows a urethral opening on the dorsal aspect of the penis, 4 mm proximal to the glans. There is a 3-cm defect in the midline abdominal wall superior to the pubic symphysis with exposure of moist, erythematous mucosa. Which of the following is the most likely underlying cause of this patient's findings?

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

Answer: Malpositioning of the genital tubercle


Context: A 37-year-old obese woman presents to the neurology clinic complaining of severe pain in her left wrist and tingling sensation in her left thumb, index finger, and middle finger, and some part of her ring finger. The pain started as an occasional throb and she could ignore it or takes analgesics but now the pain is much worse and wakes her up at night. She is also concerned that these fingers are occasionally numb and sometimes tingle. She works as a typist and her pain mostly increases after typing all day. Her right wrist and fingers are fine. Nerve conduction studies reveal nerve compression. Which of the following additional clinical findings would most likely be present in this patient?

Question: Which of the following additional clinical findings would most likely be present in this patient?

Answer: Inability to oppose thumb to other digits


Context: An otherwise healthy 45-year-old man comes to the physician because of a painful ulcer on his tongue for 3 days. Examination shows a shallow, tender 5-mm wide ulcer on the lateral aspect of the tongue, adjacent to his left first molar. There is no induration surrounding the ulcer or cervical lymphadenopathy. A lesion of the cranial nerve responsible for the transmission of pain from this ulcer would most likely result in which of the following?

Question: A lesion of the cranial nerve responsible for the transmission of pain from this ulcer would most likely result in which of the following?

Answer: Difficulty chewing


Context: A 60-year-old man has had intermittent pain in his right great toe for the past 2 years. Joint aspiration and crystal analysis shows thin, tapered, needle shaped intracellular crystals that are strongly negatively birefringent. Radiograph demonstrates joint space narrowing of the 1st metatarsophalangeal (MTP) joint with medial soft tissue swelling. What is the most likely cause of this condition?

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

Answer: Monosodium urate crystal deposition


Context: A 53-year-old man comes to the physician because of a 3-month history of a nonpruritic rash, fatigue, and decreased urination. Physical examination shows multiple erythematous, purpuric papules on his trunk and extremities that do not blanch when pressed. Serum creatinine is elevated and urinalysis shows red blood cell casts and protein. Serum complement levels are decreased. Renal biopsy shows subendothelial immune complex deposits with granular immunofluorescence and tram-track basement membrane splitting. Further laboratory evaluation of this patient is most likely to show the presence of which of the following antibodies?

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

Answer: Anti-hepatitis C antibodies


Context: A 75-year-old woman presents to the physician with a complaint of a frequent need to void at nighttime, which has been disrupting her sleep. She notes embarrassingly that she is often unable to reach the bathroom in time, and experiences urinary leakage throughout the night as well as during the day. The patient undergoes urodynamic testing and a urinalysis is obtained which is normal. She is instructed by the physician to perform behavioral training to improve her bladder control. Which of the following is the most likely diagnosis contributing to this patient’s symptoms?

Question: Which of the following is the most likely diagnosis contributing to this patient’s symptoms?

Answer: Urge incontinence


Context: A researcher is investigating whether there is an association between the use of social media in teenagers and bipolar disorder. In order to study this potential relationship, she collects data from people who have bipolar disorder and matched controls without the disorder. She then asks how much on average these individuals used social media in the 3 years prior to their diagnosis. This continuous data is divided into 2 groups: those who used more than 2 hours per day and those who used less than 2 hours per day. She finds that out of 1000 subjects, 500 had bipolar disorder of which 300 used social media more than 2 hours per day. She also finds that 400 subjects who did not have the disorder also did not use social media more than 2 hours per day. Which of the following is the odds ratio for development of bipolar disorder after being exposed to more social media?

Question: Which of the following is the odds ratio for development of bipolar disorder after being exposed to more social media?

Answer: 6


Context: A 35-year-old female presents to her primary care physician because of chronic fatigue that has stopped her from gardening and walking with her friends. Upon further questioning, she elaborates that she feels fine after waking up but gradually becomes more tired and weak as the day progresses. This appears to be particularly problematic when she is engaged in physical activity or when eating. Review of systems elicits that she occasionally experiences double vision after spending a prolonged period looking at a computer screen. Testing confirms the diagnosis and the patient is prescribed a long-acting medication to alleviate her symptoms. The products of the enzyme that is inhibited by the prescribed drug are transported by a protein that is sensitive to which of the following chemicals?

Question: The products of the enzyme that is inhibited by the prescribed drug are transported by a protein that is sensitive to which of the following chemicals?

Answer: Hemicholinium


Context: A 3-day-old newborn is brought to the physician because of abdominal distention, inconsolable crying, and 3 episodes of bilious vomiting since the previous evening. He was delivered at home at 40 weeks' gestation by a trained midwife. He has not passed meconium. Physical examination shows abdominal distention, a tight anal sphincter, and an explosive passage of air and feces on removal of the examining finger. Abnormal development of which of the following best explains this patient's condition?

Question: Abnormal development of which of the following best explains this patient's condition?

Answer: Submucosa and muscularis externa


Context:
Two days after undergoing porcine aortic valve replacement surgery for aortic valve stenosis, a 62-year-old patient develops yellow discoloration of the sclera. His vital signs are within normal limits. Physical examination shows scleral icterus. Abdominal examination shows no abnormalities. Laboratory studies show:
Hematocrit 49%
Reticulocyte count 1.2%
Serum
AST 15 U/L
ALT 18 U/L
Bilirubin, total 2.8 mg/dL
Direct 0.3 mg/dL
Lactate dehydrogenase 62 U/L
Which of the following is the most likely underlying mechanism of this patient's laboratory findings?"

Question:
Laboratory studies show:
Hematocrit 49%
Reticulocyte count 1.2%
Serum
AST 15 U/L
ALT 18 U/L
Bilirubin, total 2.8 mg/dL
Direct 0.3 mg/dL
Lactate dehydrogenase 62 U/L
Which of the following is the most likely underlying mechanism of this patient's laboratory findings?"

Answer: Impaired bilirubin conjugation


Context:
A 59-year-old woman comes to the emergency department because of a 2-day history of worsening fever, chills, malaise, productive cough, and difficulty breathing. Three days ago, she returned from a trip to South Africa. She has type 2 diabetes mellitus, hypertension, and varicose veins. Her current medications include metformin, lisinopril, and atorvastatin. Her temperature is 39.4°C (102.9°F), pulse is 102/minute, blood pressure is 94/68 mm Hg, and respirations are 31/minute. Pulse oximetry on 2 L of oxygen via nasal cannula shows an oxygen saturation of 91%. Examination reveals decreased breath sounds and dull percussion over the left lung base. The skin is very warm and well-perfused. The remainder of the examination shows no abnormalities. Laboratory studies show:
Hemoglobin 11.6 g/dL
Leukocyte count 15,400/mm3
platelet count 282,000/mm3
Serum
Na+ 144 mEq/L
Cl- 104 mEq/L
K+ 4.9 mEq/L
Creatinine 1.5 mg/dL
Blood and urine for cultures are obtained. Intravenous fluid resuscitation is begun. Which of the following is the next best step in management?"

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

Answer: Intravenous vancomycin and ceftriaxone


Context: A 30-year-old woman, gravida 1, para 0, at 30 weeks' gestation is brought to the emergency department because of progressive upper abdominal pain for the past hour. The patient vomited once on her way to the hospital. She said she initially had dull, generalized stomach pain about 6 hours prior, but now the pain is located in the upper abdomen and is more severe. There is no personal or family history of any serious illnesses. She is sexually active with her husband. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Physical examination shows right upper quadrant tenderness. The remainder of the examination shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Urinalysis shows mild pyuria. Which of the following is the most appropriate definitive treatment in the management of this patient?

Question: Which of the following is the most appropriate definitive treatment in the management of this patient?

Answer: Appendectomy


Context: A 59-year-old male with a 1-year history of bilateral knee arthritis presents with epigastric pain that intensifies with meals. He has been self-medicating with aspirin, taking up to 2,000 mg per day for the past six months. Which of the following medications, if taken instead of aspirin, could have minimized his risk of experiencing this epigastric pain?

Question: Which of the following medications, if taken instead of aspirin, could have minimized his risk of experiencing this epigastric pain?

Answer: Celecoxib


Context:
A 29-year-old woman comes to the physician because of a 2-day history of intermittent dark urine and mild flank pain. She has also had a cough, sore throat, and runny nose for the past 5 days. She has not had dysuria. She takes no medications. She has no known allergies. Her temperature is 37°C (98.6°F). Examination of the back shows no costovertebral angle tenderness. Laboratory studies show:
Hemoglobin 10.4 g/dL
Leukocyte count 8,000/mm3
Platelet count 200,000/mm3
Serum
Na+ 135 mEq/L
K+ 4.9 mEq/L
Cl- 101 mEq/L
HCO3- 22 mEq/L
Urea nitrogen 18 mg/dL
Creatinine 1.1 mg/dL
Urine
Color yellow
Blood 3+
Protein 1+
Leukocyte esterase negative
An ultrasound of the kidney and bladder shows no abnormalities. 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: Renal glomerular damage


Context: A study is being conducted on depression using the Patient Health questionnaire (PHQ-9) survey data embedded within a popular social media network with a response size of 500,000 participants. The sample population of this study is approximately normal. The mean PHQ-9 score is 14, and the standard deviation is 4. How many participants have scores greater than 22?

Question: How many participants have scores greater than 22?

Answer: 12,500


Context: A 77-year-old woman is brought to the physician for gradually increasing confusion and difficulty walking for the past 4 months. Her daughter is concerned because she has been forgetful and seems to be walking more slowly. She has been distracted during her weekly bridge games and her usual television shows. She has also had increasingly frequent episodes of urinary incontinence and now wears an adult diaper daily. She has hyperlipidemia and hypertension. Current medications include lisinopril and atorvastatin. Her temperature is 36.8°C (98.2°F), pulse is 84/min, respirations are 15/min, and blood pressure is 139/83 mmHg. She is confused and oriented only to person and place. She recalls 2 out of 3 words immediately and 1 out of 3 after five minutes. She has a broad-based gait and takes short steps. Sensation is intact and muscle strength is 5/5 throughout. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis in this patient?

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

Answer: Normal pressure hydrocephalus


Context: A 1-year-old boy is brought to the physician for the evaluation of swelling around the eyelids. He was born at term after an uncomplicated pregnancy. He is at the 95th percentile for weight and 60th percentile for length. His blood pressure is 130/86 mm Hg. Physical examination shows an empty scrotal sac and a left-sided abdominal mass. Ophthalmologic examination shows no abnormalities. Urinalysis shows a proteinuria of 3+ and fatty casts. Abdominal ultrasound shows a hypervascular mass at the upper pole of the kidney. Which of the following best describes the pathogenesis of this patient's disease?

Question: Which of the following best describes the pathogenesis of this patient's disease?

Answer: Loss of function of zinc finger transcription factor


Context: A 35-year-old female presents to her primary care physician complaining of right upper quadrant pain over the last 6 months. Pain is worst after eating and feels like intermittent squeezing. She also admits to lighter colored stools and a feeling of itchiness on her skin. Physical exam demonstrates a positive Murphy's sign. The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?

Question: The vitamin level least likely to be affected by this condition is associated with which of the following deficiency syndromes?

Answer: Scurvy


Context: On morning labs, a patient's potassium comes back at 5.9 mEq/L. The attending thinks that this result is spurious, and asks the team to repeat the electrolytes. Inadvertently, the medical student, intern, and resident all repeat the electrolytes that same morning. The following values are reported: 4.3 mEq/L, 4.2 mEq/L, and 4.2 mEq/L. What is the median potassium value for that patient that day including the first value?

Question: What is the median potassium value for that patient that day including the first value?

Answer: 4.25 mEq/L


Context: A 24-year-old woman presents to a medical office for a follow-up evaluation. The medical history is significant for type 1 diabetes, for which she takes insulin. She was recently hospitalized for diabetic ketoacidosis following a respiratory infection. Today she brings in a list of her most recent early morning fasting blood glucose readings for review. Her glucose readings range from 126 mg/dL–134 mg/dL, except for 2 readings of 350 mg/dL and 380 mg/dL, taken at the onset of her recent hospitalization. Given this data set, which measure(s) of central tendency would be most likely affected by these additional extreme values?

Question: Given this data set, which measure(s) of central tendency would be most likely affected by these additional extreme values?

Answer: Mean


Context: A 32-year-old woman comes to the physician because of a 6-week history of fatigue and weakness. Examination shows marked pallor of the conjunctivae. The spleen tip is palpated 2 cm below the left costal margin. Her hemoglobin concentration is 9.5 g/dL, serum lactate dehydrogenase concentration is 750 IU/L, and her serum haptoglobin is undetectable. A peripheral blood smear shows multiple spherocytes. When anti-IgG antibodies are added to a sample of the patient's blood, there is clumping of the red blood cells. Which of the following is the most likely predisposing factor for this patient's condition?

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

Answer: Systemic lupus erythematosus


Context:
A 4-month-old girl is seen for ongoing lethargy and vomiting. She was born to a 31-year-old G2P2 mother with a history of hypertension. She has had 7 episodes of non-bloody, non-bilious vomiting and 3 wet diapers over the last 24 hours. Laboratory results are shown below.

Serum:
Na+: 132 mEq/L
Cl-: 100 mEq/L
K+: 3.2 mEq/L
HCO3-: 27 mEq/L
BUN: 13 mg/dL
Glucose: 30 mg/dL
Lactate: 2 mmol/L
Urine ketones: < 20 mg/dL

Which of the following is the most likely diagnosis?

Question:
Serum:
Na+: 132 mEq/L
Cl-: 100 mEq/L
K+: 3.2 mEq/L
HCO3-: 27 mEq/L
BUN: 13 mg/dL
Glucose: 30 mg/dL
Lactate: 2 mmol/L
Urine ketones: < 20 mg/dL

Which of the following is the most likely diagnosis?

Answer: Medium chain acyl-CoA dehydrogenase deficiency


Context: A previously healthy 6-month-old boy is brought to the emergency department because of irritability and poor feeding for 6 days. He has also not had a bowel movement in 9 days and has been crying less than usual. He is bottle fed with formula and his mother has been weaning him with mashed bananas mixed with honey for the past 3 weeks. His immunizations are up-to-date. He appears weak and lethargic. He is at the 50th percentile for length and 75th percentile for weight. Vital signs are within normal limits. Examination shows dry mucous membranes and delayed skin turgor. There is poor muscle tone and weak head control. Neurological examination shows ptosis of the right eye. Which of the following is the most appropriate initial treatment?

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

Answer: Human-derived immune globulin


Context: A 68-year-old man comes to the emergency department 12 hours after the appearance of tender, purple discolorations on his thighs and lower abdomen. He began taking a medication 4 days ago after failed cardioversion for atrial fibrillation, but he cannot remember the name. Physical examination shows a tender bluish-black discoloration on the anterior abdominal wall. A photograph of the right thigh is shown. Which of the following is the most likely explanation for this patient's skin findings?

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

Answer: Reduced levels of protein C


Context: An 8-year-old girl is brought to the physician for a well-child examination. Since the age of 2 years, she has had multiple fractures after minor trauma. During the past year, she has fractured the left humerus and right clavicle after falls. Her father also has a history of recurrent fractures. She is at the 5th percentile for height and 20th percentile for weight. Vital signs are within normal limits. Physical examination shows increased convexity of the thoracic spine. Forward bend test demonstrates asymmetry of the thoracolumbar region. There is a curvature of the tibias bilaterally, and the left leg is 2 cm longer than the right. There is increased mobility of the joints of the upper and lower extremities. Which of the following is the most likely additional finding?

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

Answer: Hearing impairment


Context: A 59-year-old healthy woman presents to her primary care physician’s office six weeks after undergoing an elective breast augmentation procedure in the Dominican Republic. She was told by her surgeon to establish post-operative care once back in the United States. Today she is bothered by nausea and early satiety. Her past medical history is significant only for GERD for which she takes ranitidine. Since the surgery, she has also taken an unknown opioid pain medication that was given to her by the surgeon. She reports that she has been taking approximately ten pills a day. On examination she is afebrile with normal vital signs and her surgical incisions are healing well. Her abdomen is distended and tympanitic. The patient refuses to stop her pain medicine and laxatives are not effective; what medication could be prescribed to ameliorate her gastrointestinal symptoms?

Question: The patient refuses to stop her pain medicine and laxatives are not effective; what medication could be prescribed to ameliorate her gastrointestinal symptoms?

Answer: Naloxegol


Context: A 32-year-old man presents to his primary care provider reporting weakness. He recently noticed that he has difficulty letting go of a doorknob or releasing his hand after shaking hands with others. His past medical history is notable for diabetes, for which he takes metformin. He drinks 2-3 beers per day, uses marijuana occasionally, and works as a security guard. His family history is notable for an early cardiac death in his father. His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 85/min, and respirations are 18/min. On exam, there is notable muscle atrophy in his hands, feet, and neck. He has delayed hand grip release bilaterally and is slow to return from a smile to a neutral facial expression. His gait is normal, and Romberg's test is negative. He also has frontal balding. This patient’s condition is caused by a mutation in which of the following genes?

Question: This patient’s condition is caused by a mutation in which of the following genes?

Answer: DMPK


Context: A 71-year-old man presents to the emergency department for shortness of breath. The patient was returning from a business trip to China, when he suddenly felt short of breath during the taxi ride home from the airport. The patient has a past medical history of poorly controlled diabetes mellitus and a 50 pack-year smoking history. The patient is non-compliant with his medications and is currently only taking ibuprofen. An initial ECG demonstrates sinus tachycardia. A chest radiograph is within normal limits. Laboratory values are notable for a creatinine of 2.4 mg/dL and a BUN of 32 mg/dL as compared to his baseline creatinine of 0.9 mg/dL. His temperature is 98.8°F (37.1°C), pulse is 122/min, blood pressure is 145/90 mmHg, respirations are 19/min, and oxygen saturation is 93% on room air. On physical exam, you note an older gentleman in distress. Cardiac exam is notable only for tachycardia. Pulmonary exam is notable for expiratory wheezes. Which of the following is the best confirmatory test for this patient?

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

Answer: Ventilation perfusion scan


Context: A 2-week-old boy presents to the emergency department because of unusual irritability and lethargy. The patient is admitted to the pediatric intensive care unit and minutes later develops metabolic encephalopathy. This progressed to a coma, followed by death before any laboratory tests are completed. The infant was born at home via vaginal delivery at 39 weeks' of gestation. His mother says that the symptoms started since the infant was 4-days-old, but since he only seemed ‘tired’, she decided not to seek medical attention. Further testing during autopsy shows hyperammonemia, low citrulline, and increased orotic acid. Which of the following enzymes is most likely deficient in this patient?

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

Answer: Ornithine transcarbamylase


Context:
A 29-year-old woman, gravida 2, para 1, at 30 weeks' gestation comes to the emergency department because of severe right-sided back pain for the last hour. The pain is colicky and radiates to the right groin. The patient also reports nausea and pain with urination. Pregnancy has been uncomplicated and the patient reports that she has been following up with her gynecologist on a regular basis. There is no personal or family history of serious illness. She does not smoke or drink alcohol. Medications include folic acid and a multivitamin. Temperature is 37°C (98.6°F), pulse is 90/min, and blood pressure is 130/80 mm Hg. Examination of the back shows costovertebral angle tenderness on the right side. Laboratory studies show:
Urine
Protein negative
RBC casts negative
RBC 5–7/hpf
WBC casts negative
WBC 1–2/hpf
Which of the following is the most likely diagnosis?"

Question:
Laboratory studies show:
Urine
Protein negative
RBC casts negative
RBC 5–7/hpf
WBC casts negative
WBC 1–2/hpf
Which of the following is the most likely diagnosis?"

Answer: Nephrolithiasis


Context: An 18-year-old man is brought to the emergency department after his mother found him locked in his room stammering about a government conspiracy to brainwash him in subterranean tunnels. His mother says that he has never done this before, but 6 months ago he stopped going to classes and was subsequently suspended from college. She reports that he has become increasingly taciturn over the course of the past month. He drinks one to two beers daily and has smoked one pack of cigarettes daily for 3 years. He occasionally smokes marijuana. His father was diagnosed with schizophrenia at the age of 25 years. The patient has had no friends or social contacts other than his mother since he was suspended. He appears unkempt and aloof. On mental status examination, he is disorganized and shows poverty of speech. He says his mood is “good.” He does not hear voices and has no visual or tactile hallucinations. Toxicology screening is negative. Which of the following is a favorable prognostic factor for this patient's condition?

Question: Which of the following is a favorable prognostic factor for this patient's condition?

Answer: Acute onset of symptoms


Context: An investigator studying patients with symptoms of arthritis detects a nonenveloped virus with a single-stranded DNA genome in the serum of a pregnant patient. Fetal infection with this pathogen is most likely to cause which of the following manifestations?

Question: Fetal infection with this pathogen is most likely to cause which of the following manifestations?

Answer: Hydrops fetalis


Context: A 32-year-old man comes to the Veterans Affairs hospital because of difficulty sleeping for the past 9 weeks. He is a soldier who returned from a deployment in Afghanistan 12 weeks ago. Fifteen weeks ago, his unit was ambushed in a deserted street, and a fellow soldier was killed. He wakes up frequently during the night from vivid dreams of this incident. He blames himself for being unable to save his friend. He also has trouble falling asleep and gets up earlier than desired. During this period, he has started to avoid walking in deserted streets. Vital signs are within normal limits. Physical examination shows no abnormalities. He refuses cognitive behavioral therapy and is started on sertraline. Five weeks later, he returns to the physician and complains about persistent nightmares and difficulty sleeping. 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: Prazosin therapy


Context: A 32-year-old woman is brought into the emergency department at 5 AM because of chest pain that woke her up at 3 AM. The pain is constant and has not decreased in intensity during this time. She has no history of any similar episodes. She has systemic lupus erythematosus without major organ involvement. She takes prednisone, calcium, alendronate, and hydroxychloroquine. The blood pressure is 120/75 mm Hg, pulse is 85/min, respirations are 19/min, and the temperature is 36.5°C (97.7°F). An examination of the chest including the heart and lungs shows no abnormalities. The electrocardiogram (ECG) shows no abnormalities. Computed tomography (CT) scan of the chest shows esophageal thickening near the mid-portion. Which of the following is the most likely diagnosis?

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

Answer: Pill esophagitis


Context: Six hours after near-total thyroidectomy for Graves disease, a 58-year-old man has not had any urine output. The surgery was successful and the patient feels well except for slight neck pain. He has type 2 diabetes mellitus and hypertension. His father had autosomal dominant polycystic kidney disease. Prior to the surgery, the patient was taking metformin and lisinopril regularly and ibuprofen as needed for headaches. His current medications include acetaminophen and codeine. His temperature is 36.2°C (97.2°F), pulse is 82/min, and blood pressure is 122/66 mm Hg. Physical examination shows a 7-cm surgical wound on the anterior neck with mild swelling, but no reddening or warmth. 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: Perform bedside bladder scan


Context: A 45-year-old man presents to his primary care physician because of abdominal pain. He has had this pain intermittently for several years but feels that it has gotten worse after he started a low carbohydrate diet. He says that the pain is most prominent in the epigastric region and is also associated with constipation and foul smelling stools that float in the toilet bowl. He has a 15-year history of severe alcoholism but quit drinking 1 year ago. Laboratory studies are obtained showing a normal serum amylase and lipase. Both serum and urine toxicology are negative. His physician starts him on appropriate therapy and checks to make sure that his vitamin and mineral levels are appropriate. Which of the following deficiency syndromes is most closely associated with the cause of this patient's abdominal pain?

Question: Which of the following deficiency syndromes is most closely associated with the cause of this patient's abdominal pain?

Answer: Osteomalacia


Context: A 67-year-old man comes to the physician because of a 6-month history of increasing shortness of breath on exertion, dry cough, and fatigue. He has not had any fevers or night sweats. He worked in a glass manufacturing factory for 15 years and retired 2 years ago. Pulmonary examination shows diffuse crackles bilaterally. An x-ray of the chest shows well-defined calcification of the rims of hilar lymph nodes and scattered nodules in both upper lung fields. This patient is most likely to develop which of the following complications?

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

Answer: Pulmonary tuberculosis


Context: A 47-year-old woman comes to the physician because of fatigue, difficulty falling asleep, and night sweats for the past 6 months. Over the past year, her menstrual cycle has become irregular and her last menstrual period was 2 months ago. She quit smoking 2 years ago. Pelvic exam shows vulvovaginal atrophy. A pregnancy test is negative. Which of the following changes is most likely to occur in this patient's condition?

Question: Which of the following changes is most likely to occur in this patient's condition?

Answer: Increased follicle-stimulating hormone


Context: A 41-year-old woman presents with back pain for the past 2 days. She says that the pain radiates down along the posterior right thigh and leg. She says the pain started suddenly after lifting a heavy box 2 days ago. Past medical history is irrelevant. Physical examination reveals a straight leg raise (SLR) test restricted to 30°, inability to walk on her toes, decreased sensation along the lateral border of her right foot, and diminished ankle jerk on the same side. Which of the following nerve roots is most likely compressed?

Question: Which of the following nerve roots is most likely compressed?

Answer: First sacral nerve root (S1)


Context: A 72-year-old woman comes to the physician because of a 3-day history of redness and swelling of her right leg and fever. She says the leg is very painful and the redness over it has become larger. She appears ill. Her temperature is 39.3°C (102.7°F), pulse is 103/min, and blood pressure is 138/90 mm Hg. Cardiopulmonary examination shows no abnormalities. Examination shows an area of diffuse erythema and swelling over her anterior right lower leg; it is warm and tender to touch. Squeezing of the calf does not elicit tenderness. There is swelling of the right inguinal lymph nodes. Pedal pulses are palpable bilaterally. Which of the following is the strongest predisposing factor for this patient's condition?

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

Answer:
Tinea pedis
"


Context: A 35-year-old female presents to the emergency room complaining of diarrhea and dehydration. She has been experiencing severe watery diarrhea for the past 3 days. She reports that she has been unable to leave the bathroom for more than a few minutes at a time. She noticed earlier today that there was some blood on her toilet paper after wiping. She recently returned from a volunteer trip to Yemen where she worked at an orphanage. Her past medical history is notable for psoriasis for which she takes sulfasalazine. The patient drinks socially and does not smoke. Her temperature is 99°F (37.2°C), blood pressure is 100/55 mmHg, pulse is 130/min, and respirations are 20/min. Mucus membranes are dry. Her eyes appear sunken. Capillary refill is 4 seconds. The patient is started on intravenous fluid resuscitation. Which of the following processes is capable of transmitting the genetic material for the toxin responsible for this patient’s condition?

Question: Which of the following processes is capable of transmitting the genetic material for the toxin responsible for this patient’s condition?

Answer: Transduction


Context: A 3-year-old toddler was rushed to the emergency department after consuming peanut butter crackers at daycare. The daycare staff report that the patient has a severe allergy to peanut butter and he was offered the crackers by mistake. The patient is in acute distress. The vital signs include: blood pressure 60/40 mm Hg and heart rate 110/min. There is audible inspiratory stridor and the respiratory rate is 27/min. Upon examination, his chest is covered in a maculopapular rash. Intubation is attempted and failed due to extensive laryngeal edema. The decision for cricothyrotomy is made. Which of the following is the most likely mechanism of this pathology?

Question: Which of the following is the most likely mechanism of this pathology?

Answer: Release of IL-4


Context: A 32-year-old G2P0 presents at 37 weeks gestation with a watery vaginal discharge. The antepartum course was remarkable for an abnormal ultrasound finding at 20 weeks gestation. The vital signs are as follows: blood pressure, 110/80 mm Hg; heart rate, 91/min; respiratory rate, 13/min; and temperature, 36.4℃ (97.5℉). The fetal heart rate is 141/min. On speculum examination, there were no vaginal or cervical lesions, but there is a continuous watery vaginal discharge with traces of blood. The discharge is fern- and nitrite-positive. Soon after the initial examination, the bleeding increases. Fetal monitoring shows a heart rate of 103/min with late decelerations. Which of the following ultrasound findings was most likely present in the patient and predisposed her to the developed condition?

Question: Which of the following ultrasound findings was most likely present in the patient and predisposed her to the developed condition?

Answer: Velamentous cord insertion


Context: An experimental drug, ES 62, is being studied. It prohibits the growth of vancomycin-resistant Staphylococcus aureus. It is highly lipid-soluble. The experimental design is dependent on a certain plasma concentration of the drug. The target plasma concentration is 100 mmol/dL. Which of the following factors is most important for calculating the appropriate loading dose?

Question: Which of the following factors is most important for calculating the appropriate loading dose?

Answer: Volume of distribution


Context: A 24-year-old male graduate student comes to the physician for a two-month history of repeated thoughts and anxiety that he is going to be harmed by someone on the street. The anxiety worsened after witnessing a pedestrian getting hit by a car two weeks ago. He says, “That was a warning sign.” On his way to school, he now often leaves an hour earlier to take a detour and hide from people that he thinks might hurt him. He is burdened by his coursework and fears that his professors are meaning to fail him. He says his friends are concerned about him but that they do not understand because they were not present at the accident. The patient has no known history of psychiatric illness. On mental status exam, he is alert and oriented, and shows full range of affect. Thought processes and speech are organized. His memory and attention are within normal limits. He denies auditory, visual, or tactile hallucinations. Urine toxicology screening is negative. Which of the following is the most likely diagnosis in this patient?

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

Answer: Delusional disorder


Context:
A 58-year-old male presents to the clinic for a follow-up visit. He takes metformin every day and says that he is compliant with his medication but can not control his diet. Three months prior, his HbA1c was 8.2% when he was started on metformin. He does not have any complaints on this visit. His temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min and blood pressure is 122/88 mm Hg. His BMI is 33. Physical examination is within normal limits. Blood is drawn for laboratory tests and the results are given below:
Fasting blood glucose 150 mg/dL
Glycated hemoglobin (HbA1c) 7.2 %
Serum Creatinine 1.1 mg/dL
BUN 12 mg/dL
The physician wants to initiate another medication for his blood glucose control, specifically one that does not carry a risk of weight gain. Addition of which of the following drugs would be most suitable for this patient?

Question: Addition of which of the following drugs would be most suitable for this patient?

Answer: Sitagliptin


Context: A 24-year-old man presents to the college campus clinic worried that he is having a nervous breakdown. The patient was diagnosed with attention-deficit/hyperactivity disorder (ADHD) during his freshman year and has been struggling to keep his grades up. He has recently become increasingly worried that he might not be able to graduate on time. For the past 2-months, he has been preoccupied with thoughts of his dorm room burning down and he finds himself checking all the appliances and outlets over and over even though he knows he already checked everything thoroughly. This repetitive behavior makes him late to class and has seriously upset his social activities. The patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Which of the following psychiatric disorders is most associated with this patient’s condition?

Question: Which of the following psychiatric disorders is most associated with this patient’s condition?

Answer: Tourette syndrome


Context: A 49-year-old male complains of abdominal discomfort that worsens following meals. A gastric biopsy reveals a 2 cm gastric ulcer, and immunohistochemical staining demonstrates the presence of a rod-shaped bacterium in the gastric mucosa. Which of the following is used by the infiltrating pathogen to neutralize gastric acidity?

Question: Which of the following is used by the infiltrating pathogen to neutralize gastric acidity?

Answer: Urease


Context: A 7-year-old boy is brought to the emergency department by his mother 1 hour after falling off his bike and landing head-first on the pavement. His mother says that he did not lose consciousness but has been agitated and complaining about a headache since the event. He has no history of serious illness and takes no medications. His temperature is 37.1°C (98.7°F), pulse is 115/min, respirations are 20/min, and blood pressure is 100/65 mm Hg. There is a large bruise on the anterior scalp. Examination, including neurologic examination, shows no other abnormalities. A noncontrast CT scan of the head shows a non-depressed linear skull fracture with a 2-mm separation. 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: Inpatient observation


Context:
A 67-year-old man presents to the emergency department with altered mental status. The patient is non-verbal at baseline, but his caretakers at the nursing home noticed he was particularly somnolent recently. The patient has a past medical history of diabetes and Alzheimer dementia. His temperature is 99.7°F (37.6°C), blood pressure is 157/98 mmHg, pulse is 150/min, respirations are 16/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below.

Hemoglobin: 9 g/dL
Hematocrit: 33%
Leukocyte count: 8,500/mm^3 with normal differential
Platelet count: 197,000/mm^3

Serum:
Na+: 139 mEq/L
Cl-: 102 mEq/L
K+: 4.3 mEq/L
HCO3-: 25 mEq/L
BUN: 37 mg/dL
Glucose: 99 mg/dL
Creatinine: 2.4 mg/dL
Ca2+: 12.2 mg/dL

The patient has lost 20 pounds over the past month. His parathyroid hormone is within normal limits, and his urinary calcium is increased. Physical exam demonstrates discomfort when the patient's lower back and extremities are palpated. Which of the following is the most accurate diagnostic test for this patient's underlying diagnosis?

Question: Which of the following is the most accurate diagnostic test for this patient's underlying diagnosis?

Answer: Bone marrow biopsy


Context: A 31-year-old G1P0 woman is brought into the emergency room by the police after a failed suicide attempt. She jumped off a nearby bridge but was quickly rescued by some nearby locals. The height of the bridge was not significant, so the patient did not sustain any injuries. For the 3 weeks before this incident, the patient says she had been particularly down, lacking energy and unable to focus at home or work. She says she no longer enjoys her usual hobbies or favorite meals and is not getting enough sleep. Which of the following is the best course of treatment for this patient?

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

Answer: Electroconvulsive therapy


Context: A 35-year-old woman is brought into the emergency room by her boyfriend with a superficial cut to the wrist. Her vital signs are normal.  On physical examination, the laceration is superficial and bleeding has stopped. She says that the injury was self-inflicted because her boyfriend canceled a dinner date due to his mother being unexpectedly hospitalized. She had tried to call, email, and text him to make sure he kept the date, but he eventually stopped replying to her messages. She loves her boyfriend and says she cannot live without him. However, she was worried that he might be cheating on her and using his mother as an excuse. She admits, however, that he actually has never cheated on her in the past. While she says that she usually feels emotionally empty, she is furious during the interview as she describes how much she hates her boyfriend. Which of the following defense mechanisms is this patient exhibiting?

Question: Which of the following defense mechanisms is this patient exhibiting?

Answer: Splitting


Context: A 29-year-old female presents to the family physician concerned over the blue-black discoloration of her sclera and skin. She notes that at the end of her day, there are black stains in her underwear. The incomplete breakdown of which of the following amino acids is responsible for this presentation?

Question: The incomplete breakdown of which of the following amino acids is responsible for this presentation?

Answer: Tyrosine


Context: A 35-year-old woman presents as a new patient to a primary care physician. She hasn't seen a doctor in many years and came in for a routine check-up. She has no specific complaints, although she has occasional shortness of breath with mild activity. On physical exam, her vital signs are as follows: HR 80, BP 110/70, RR 14. On auscultation, her lungs are clear with equal breath sounds bilaterally. When listening over the precordium, the physician hears a mid-systolic click followed by a late systolic murmur that is loudest over the apex. Valsalva increases the murmur. Which of the following is NOT a possible complication of this patient's underlying problem?

Question: Which of the following is NOT a possible complication of this patient's underlying problem?

Answer: Bleeding from acquired von Willebrand disease


Context:
A 30-year-old woman seeks evaluation at a clinic complaining of shaking, chills, fevers, and headaches for the last 3 days. She recently returned from a trip to India, where she was visiting her family. There is no history of loss of consciousness or respiratory distress. The vital signs include temperature 38.9℃ (102.0℉), respiratory rate 19/min, blood pressure 120/80 mm Hg, and pulse 94/min (rapid and thready). On general examination, she is pale and the sclera is jaundiced. Laboratory studies show:
Hematocrit (Hct) 30%
Total bilirubin  2.6 mg/dL
Direct bilirubin  0.3 mg/dL
A peripheral smear is shown below. What is the most severe complication of this condition?

Question: What is the most severe complication of this condition?

Answer: Cerebral edema


Context: A 13-year-old girl is brought to the physician by her mother because of a 1-year history of worsening clumsiness. Initially, she swayed while walking; over the past 3 months, she has fallen 4 times. Ophthalmic examination shows a horizontal nystagmus. Proprioception and vibratory sensation are decreased in the distal extremities. Deep tendon reflexes are 1+ bilaterally. Further evaluation of the patient shows a genetic disorder involving an iron-binding mitochondrial protein encoded on chromosome 9. Which of the following findings is most likely to also be seen in this patient?

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

Answer: Hammer toes


Context: A 36-year-old man comes to the physician because of a 2-day history of malaise and a painful, pruritic rash on his lower back and thighs. His temperature is 37.8°C (100°F). Physical examination shows the findings in the photograph. Skin scrapings from the thigh grow neutral colonies on MacConkey agar. The colony-producing bacteria are oxidase-positive. Which of the following is the greatest risk factor for the patient's condition?

Question: Which of the following is the greatest risk factor for the patient's condition?

Answer: Swimming in pool


Context: A 2-month-old baby boy and his mother present to his pediatrician for vaccination as per the immunization schedule. His mother denies any active complaints but mentions that he has not smiled yet. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. His mother received minimal prenatal care. On physical examination, his vitals are stable, but a general examination shows the presence of generalized hypotonia. His face is characterized by upwardly slanting palpebral fissures, small dysplastic ears, and a flat face. His little fingers are short, with clinodactyly, and both palms have single palmar creases. The results of a karyotype are shown in the image. If this infant has also inherited a mutation in the GATA1 gene, for which of the following conditions is he most likely to be at increased risk?

Question: If this infant has also inherited a mutation in the GATA1 gene, for which of the following conditions is he most likely to be at increased risk?

Answer: Acute megakaryoblastic leukemia


Context: A 28-year-old woman presents to the emergency department with fever, cough, and difficulty in breathing for the last 6 hours. She also mentions that she noticed some blood in her sputum an hour ago. She denies nasal congestion or discharge, sneezing, wheezing, chest pain, or palpitation. Her past history does not suggest any chronic medical condition, including respiratory disease, cardiovascular disease, or cancer. There is no history of pulmonary embolism or deep vein thrombosis in the past. Her temperature is 38.3°C (101.0°F ), the pulse is 108/min, the blood pressure is 116/80 mm Hg, and the respirations are 28/min. Auscultation of her lungs reveals the presence of localized crackles over the right inframammary region. Edema is present over her left leg and tenderness is present over her left calf region. When her left foot is dorsiflexed, she complains of calf pain. The emergency department protocol mandates the use of a modified Wells scoring system in all patients presenting with the first episode of breathlessness when there is no history of a cardiorespiratory disorder in the past. Using the scoring system, the presence of which of the following risk factors would suggest a high clinical probability of pulmonary embolism?

Question: Using the scoring system, the presence of which of the following risk factors would suggest a high clinical probability of pulmonary embolism?

Answer: History of surgery within the last 30 days


Context: A 62-year-old man comes to the physician because of a 5-day history of swelling in his left arm. Two months ago, he was diagnosed with a deep venous thrombosis in the left calf. He has had a 7-kg (15-lb) weight loss in the last 3 months. He has smoked 1 pack of cigarettes daily for the past 25 years. His only medication is warfarin. Physical examination shows warm edema of the left forearm with overlying erythema and a tender, palpable cord-like structure along the medial arm. His lungs are clear to auscultation bilaterally. Duplex sonography shows thrombosis of the left basilic and external jugular veins. Which of the following is the most appropriate next step to confirm the underlying diagnosis?

Question: Which of the following is the most appropriate next step to confirm the underlying diagnosis?

Answer: CT scan of the abdomen


Context: A 24-day-old infant girl is brought to the emergency department because of a 2-hour history of fever, vomiting, and diarrhea. She has fed less and has had decreased urine output for 1 day. She was born at 33 weeks' gestation and weighed 1400-g (3-lb 1-oz). Her diet consists of breast milk and cow milk protein-based formula. Examination shows abdominal rigidity, distention, and absent bowel sounds. Test of the stool for occult blood is positive. An x-ray of the abdomen shows gas within the intestinal wall and the peritoneal cavity. Which of the following is the most likely diagnosis?

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

Answer: Necrotizing enterocolitis


Context: A previously healthy 42-year-old woman comes to the physician because of a 7-month history of diffuse weakness. There is no cervical or axillary lymphadenopathy. Cardiopulmonary and abdominal examination shows no abnormalities. A lateral x-ray of the chest shows an anterior mediastinal mass. 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: Acetylcholine receptor antibodies


Context: A 17-year-old patient presents to the emergency department with left wrist pain after falling off of his bike and landing on his left hand. On physical exam the thenar eminence is red, swollen, and tender to palpation, so a radiograph is ordered. The patient is worried because he learned in biology class that radiography can cause cancer through damaging DNA but the physician reassures him that radiographs give a very minor dose of radiation. What is the most common mechanism by which ionizing radiation damages DNA?

Question: What is the most common mechanism by which ionizing radiation damages DNA?

Answer: Strand breakage


Context: A 34-year-old G3P2 presents at 33 weeks gestation with vaginal bleeding that started last night while she was asleep. She denies uterine contractions or abdominal pain. She had a cesarean delivery in her previous pregnancy. She also reports a 10 pack-year smoking history. The vital signs are as follows: blood pressure, 130/80 mm Hg; heart rate, 84/min; respiratory rate, 12/min; and temperature, 36.8℃ (98.2℉). The physical examination is negative for abdominal tenderness or palpable uterine contractions. The perineum is mildly bloody. On speculum examination, no vaginal or cervical lesions are seen. A small amount of blood continues to pass through the cervix. Which of the following findings would you expect on ultrasound examination?

Question: Which of the following findings would you expect on ultrasound examination?

Answer: Partial covering of the internal cervical os by the placental edge


Context: A group of scientists is conducting an experiment on the human cells involved in the immune response. They genetically modify B cells so they do not express the cluster of differentiation 21 (CD21) on their cell surfaces. The pathogenesis of which of the following organisms would most likely be affected by this genetic modification?

Question: The pathogenesis of which of the following organisms would most likely be affected by this genetic modification?

Answer: Epstein-Barr virus (EBV)


Context: A 13-year-old boy is brought to the physician by his parents, who are concerned about recurrent muscle cramps he experiences while playing soccer. The boy has always loved sports and has been playing in a soccer league for the past 3 years. He now complains of severe cramping pain in his legs after intense practice sessions. He has no significant medical history. His physical examination is unremarkable. A battery of laboratory tests is ordered and they are all normal. Imaging studies yield no abnormalities as well. Which of the following is most likely deficient in this patient?

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

Answer: Carnitine palmitoyltransferase II


Context: A 40-year-old male presents to his primary care physician for a regularly scheduled check-up. Physical examination reveals nontender cervical lymphadenopathy. A biopsy of the lymph node reveals aggregates of follicular architecture, and cytogenic analysis shows a t(14;18) translocation. The protein most likely responsible for the patient’s condition does which of the following:

Question: The protein most likely responsible for the patient’s condition does which of the following:

Answer: Inhibits apoptosis


Context: A 25-year-old woman comes to the physician for the evaluation of blindness in her right eye that suddenly started 1 hour ago. She has no feeling of pain, pressure, or sensation of a foreign body in the right eye. She has a history of major depressive disorder treated with fluoxetine. The patient attends college and states that she has had a lot of stress lately due to relationship problems with her partner. She does not smoke or drink alcohol. She does not use illicit drugs. She appears anxious. Her vital signs are within normal limits. Ophthalmologic examination shows a normal-appearing eye with no redness. Slit lamp examination and fundoscopy show no abnormalities. A visual field test shows nonspecific visual field defects. An MRI of the brain shows no abnormalities. Which of the following is the most likely diagnosis?

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

Answer: Conversion disorder


Context: A 52-year-old woman presents to the clinic with several days of vomiting and diarrhea. She also complains of headaches, muscle aches, and fever, but denies tenesmus, urgency, and bloody diarrhea. Past medical history is insignificant. When asked about any recent travel she says that she just came back from a cruise ship vacation. Her temperature is 37°C (98.6° F), respiratory rate is 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Physical examination is non-contributory. Microscopic examination of the stool is negative for ova or parasites. What is the most likely diagnosis?

Question: What is the most likely diagnosis?

Answer: Norovirus infection


Context: A 34-year-old female presents to the emergency room with headache and palpitations. She is sweating profusely and appears tremulous on exam. Vital signs are as follows: HR 120, BP 190/110, RR 18, O2 99% on room air, and Temp 37C. Urinary metanephrines and catechols are positive. Which of the following medical regimens is contraindicated as a first-line therapy in this patient?

Question: Which of the following medical regimens is contraindicated as a first-line therapy in this patient?

Answer: Propranolol


Context: A 9-year-old boy is brought to the physician for evaluation of short stature. He is at the 5th percentile for height, 65th percentile for weight, and 95th percentile for head circumference. Examination shows midface retrusion, a bulging forehead, and flattening of the nose. The extremities are disproportionately short. He was adopted and does not know his biological parents. The patient’s condition is an example of which of the following genetic phenomena?

Question: The patient’s condition is an example of which of the following genetic phenomena?

Answer: Complete penetrance


Context: A 33-year-old woman comes to the physician for week-long episodes of headaches that have occurred every four weeks for the last year. During these episodes she also has bouts of lower abdominal pain and breast tenderness. She is often irritable at these times. Her menses occur at regular 28-day intervals with moderate flow. Her last menstrual period was 3 weeks ago. She drinks two to five beers on social occasions and used to smoke a pack of cigarettes daily, but stopped 6 months ago. Her mother and sister have hypothyroidism. Physical examination shows no abnormalities. Which of the following is most likely to confirm the diagnosis?

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

Answer: Maintaining a menstrual diary


Context: A 51-year-old woman presents for her annual wellness visit. She says she feels healthy and has no specific concerns. Past medical history is significant for bipolar disorder, hypertension, and diabetes mellitus type 2, managed with lithium, lisinopril, and metformin, respectively. Her family history is significant for hypertension and diabetes mellitus type 2 in her father, who died from lung cancer at age 67. Her vital signs include: temperature 36.8°C (98.2°F), pulse 97/min, respiratory rate 16/min, blood pressure 120/75 mm Hg. Physical examination is unremarkable. Mammogram findings are labeled breast imaging reporting and data system-3 (BIRADS-3) (probably benign). Which of the following is the next best step in management in this patient?

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

Answer: Follow-up mammogram in 6 months


Context: A 37-year-old woman comes to the physician because of right-sided inguinal pain for the past 8 weeks. During this period, the patient has had increased pain during activities such as walking and standing. She has no nausea, vomiting, or fever. Her temperature is 36.8°C (98.2°F), pulse is 73/min, and blood pressure is 132/80 mm Hg. The abdomen is soft and nontender. There is a visible and palpable groin protrusion above the inguinal ligament on the right side. Bulging is felt during Valsalva maneuver. Which of the following is the most likely diagnosis?

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

Answer: Indirect inguinal hernia


Context: A 45-year-old man presents to the emergency department with decreased exercise tolerance and shortness of breath which has progressed slowly over the past month. The patient recalls that shortly before the onset of these symptoms, he had a low-grade fever, malaise, and sore throat which resolved after a few days with over the counter medications. He does not have any chronic illnesses and denies recent travel or illicit habits. His vital signs include: blood pressure 120/80 mm Hg, temperature 37.0°C (98.6°F), and regular radial pulse 90/min. While checking his blood pressure manually, the difference between the systolic pressure at which the first Korotkoff sounds are heard during expiration and the pressure at which they are heard throughout the respiratory cycle is less than 10 mm Hg. On physical examination, he is in mild distress with jugular venous pressure (JVP) of 13 cm, and his heart sounds are muffled. His echocardiography shows a fluid collection in the pericardial sac with no evidence of right ventricular compression. Which of the following is the best initial step for the treatment of this patient?

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

Answer: Observation and anti-inflammatory medicines


Context: A 5-year-old boy is brought to the physician for excessive weight gain. The mother reports that her son has been “chubby” since he was a toddler and that he has gained 10 kg (22 lbs) over the last year. During this period, he fractured his left arm twice from falling on the playground. He had cryptorchidism requiring orchiopexy at age 2. He is able to follow 1-step instructions and uses 2-word sentences. He is at the 5th percentile for height and 95th percentile for weight. Vital signs are within normal limits. Physical examination shows central obesity. There is mild esotropia and coarse, dry skin. In addition to calorie restriction, which of the following is the most appropriate next step in management of this patient?

Question: In addition to calorie restriction, which of the following is the most appropriate next step in management of this patient?

Answer: Growth hormone and testosterone


Context: A 40-year-old man comes to the physician because of a 2-year history of gradually worsening shortness of breath. He smoked half a pack of cigarettes daily for 10 years but stopped 8 years ago. His pulse is 72/min, blood pressure is 135/75 mm Hg, and respirations are 20/min. Examination shows an increased anteroposterior diameter of the chest. Diminished breath sounds are heard on auscultation of the chest. An x-ray of the chest shows widened intercostal spaces, a flattened diaphragm, and bilateral hyperlucency of the lung bases. This patient's condition puts him at greatest risk for which of the following conditions?

Question: This patient's condition puts him at greatest risk for which of the following conditions?

Answer: Hepatocellular carcinoma


Context: A 3-year-old boy presents to an urgent care clinic with his mother. She states that his behavior has been lethargic for the past 3 days. She also notes that he has had a runny nose, mild cough, and sore throat during this time. She does not believe that he has been febrile. His temperature is 99.1°F (37.2°C), blood pressure is 105/67 mmHg, pulse is 100/min, respirations are 18/min, and SpO2 97% on room air. Which nucleic acid structure most accurately describes the most likely virus responsible for this boy’s clinical condition?

Question: Which nucleic acid structure most accurately describes the most likely virus responsible for this boy’s clinical condition?

Answer: Single-stranded, positive-sense RNA


Context: A 26-year-old male with no significant past medical history goes camping with several friends in Virginia. Several days after returning, he begins to experience fevers, headaches, myalgias, and malaise. He also notices a rash on his wrists and ankles (FIgure A). Which of following should be initiated for treatment of his condition?

Question: Which of following should be initiated for treatment of his condition?

Answer: Doxycycline


Context:
An obese 63-year-old man comes to the physician because of 3 episodes of red urine over the past week. He has also had recurrent headaches and intermittent blurry vision during the past month. He has benign prostatic hyperplasia. He works as an attendant at a gas station. The patient has smoked one pack of cigarettes daily for the last 40 years. He does not drink alcohol. Current medications include tamsulosin. His temperature is 37.4°C (99.4°F), pulse is 90/min, and blood pressure is 152/95 mm Hg. Examination shows a flushed face. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and non-tender. Digital rectal examination shows an enlarged prostate with no nodules. Urinalysis shows:
Blood 3+
Glucose negative
Protein negative
WBC 1-2/hpf
RBC 40-45/hpf
RBC casts none
Which of the following is the most likely diagnosis?"

Question:
Urinalysis shows:
Blood 3+
Glucose negative
Protein negative
WBC 1-2/hpf
RBC 40-45/hpf
RBC casts none
Which of the following is the most likely diagnosis?"

Answer: Renal cell carcinoma


Context: A 24-year-old man presents to the emergency department after a suicide attempt. He is admitted to the hospital and diagnosed with schizoaffective disorder. A review of medical records reveals a history of illicit drug use, particularly cocaine and amphetamines. He is started on aripiprazole, paroxetine, and trazodone. At the time of discharge, he appeared more coherent and with a marked improvement in positive symptoms of hallucinations and delusions but still with a flat effect. During the patient’s first follow-up visit, his mother reports he has become increasingly agitated and restless despite compliance with his medications. She reports that her son’s hallucinations and delusions have stopped and he does not have suicidal ideations, but he cannot sit still and continuously taps his feet, wiggles his fingers, and paces in his room. When asked if anything is troubling him, he stands up and paces around the room. He says, “I cannot sit still. Something is happening to me.” A urine drug screen is negative. What is the next best step in the management of this patient?

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

Answer: Add propranolol


Context: A 55-year-old man visits the clinic with his wife. He has had difficulty swallowing solid foods for the past 2 months. His wife adds that his voice is getting hoarse but they thought it was due to his recent flu. His medical history is significant for type 2 diabetes mellitus for which he is on metformin. He suffered from many childhood diseases due to lack of medical care and poverty. His blood pressure is 125/87 mm Hg, pulse 95/min, respiratory rate 14/min, and temperature 37.1°C (98.7°F). On examination, an opening snap is heard over the cardiac apex. An echocardiogram shows an enlarged cardiac chamber pressing into his esophagus. Changes in which of the following structures is most likely responsible for this patient’s symptoms?

Question: Changes in which of the following structures is most likely responsible for this patient’s symptoms?

Answer: Left atrium


Context: A 2-year-old boy is brought to the physician for generalized fatigue and multiple episodes of abdominal pain and vomiting for the past week. His last bowel movement was 4 days ago. He has been having behavioral problems at home for the past few weeks as well. He can walk up stairs with support and build a tower of 3 blocks. He cannot use a fork. He does not follow simple instructions and speaks in single words. His family emigrated from Bangladesh 6 months ago. He is at the 40th percentile for height and weight. His temperature is 37°C (98.6°F), pulse is 115/min, and blood pressure is 84/45 mm Hg. Examination shows pale conjunctivae and gingival hyperpigmentation. His hemoglobin concentration is 10.1 g/dL, mean corpuscular volume is 68 μm3, and mean corpuscular hemoglobin is 24.5 pg/cell. The patient is most likely going to benefit from administration of which of the following?

Question: The patient is most likely going to benefit from administration of which of the following?

Answer: Succimer and calcium disodium edetate


Context:
A 74-year-old man presents to the emergency department by paramedics for slurred speech and weakness in the left arm and leg for 1 hour. The patient was playing with his grandson when the symptoms started and his wife immediately called an ambulance. There is no history of head trauma or recent surgery. The patient takes captopril for hypertension. The vital signs include: pulse 110/min, respiratory rate 22/min, and blood pressure 200/105 mm Hg. The physical examination shows that the patient is alert and conscious, but speech is impaired. Muscle strength is 0/5 in the left arm and leg and 5/5 in the right arm and leg. A non-contrast CT of the head shows no evidence of intracranial bleeding. The lab results are as follows:
Serum glucose 90 mg/dL
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 1.3 mg/dL
Blood urea nitrogen 20 mg/dL
Cholesterol, total 240 mg/dL
HDL-cholesterol 38 mg/dL
LDL-cholesterol 100 mg/dL
Triglycerides 190 mg/dL
Hemoglobin (Hb%) 15.3 g/dL
Mean corpuscular volume (MCV) 83 fL
Reticulocyte count 0.8%
Erythrocyte count 5.3 million/mm3
Platelet count 130,000/mm3
Partial thromboplastin time (aPTT)  30 sec
Prothrombin time (PT) 12 sec
Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?

Question:
The lab results are as follows:
Serum glucose 90 mg/dL
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 1.3 mg/dL
Blood urea nitrogen 20 mg/dL
Cholesterol, total 240 mg/dL
HDL-cholesterol 38 mg/dL
LDL-cholesterol 100 mg/dL
Triglycerides 190 mg/dL
Hemoglobin (Hb%) 15.3 g/dL
Mean corpuscular volume (MCV) 83 fL
Reticulocyte count 0.8%
Erythrocyte count 5.3 million/mm3
Platelet count 130,000/mm3
Partial thromboplastin time (aPTT)  30 sec
Prothrombin time (PT) 12 sec
Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?

Answer: Systolic blood pressure of 200 mm Hg


Context: A 33-year-old African American woman presents to the office complaining of blurry vision and headache for the past 2 weeks. She states that she has not been feeling herself lately and also fell down once after a dizzy episode. Her medical history is remarkable for hypertension and pulmonary sarcoidosis treated with hydralazine and prednisone respectively. She had a recent bout of acute optic neuritis, requiring high-dose IV methylprednisolone. Her temperature is 37°C (98.6°F), the blood pressure is 112/76 mm Hg, the pulse is 78/min, and the respirations are 14/min. On examination, the patient is mildly disoriented. Head and neck examination reveals a soft, supple neck and a right-sided facial droop. There is 5/5 muscle strength in all extremities. VDRL test is negative. A head MRI is pending. What is the most appropriate next step in the management of this patient?

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

Answer: Methylprednisolone and methotrexate


Context: A 54-year-old man comes to the emergency department because of episodic palpitations for the past 12 hours. He has no chest pain. He has coronary artery disease and type 2 diabetes mellitus. His current medications include aspirin, insulin, and atorvastatin. His pulse is 155/min and blood pressure is 116/77 mm Hg. Physical examination shows no abnormalities. An ECG shows monomorphic ventricular tachycardia. An amiodarone bolus and infusion is given, and the ventricular tachycardia converts to normal sinus rhythm. He is discharged home with oral amiodarone. Which of the following is the most likely adverse effect associated with long-term use of this medication?

Question: Which of the following is the most likely adverse effect associated with long-term use of this medication?

Answer: Chronic interstitial pneumonitis


Context: A 24-year-old woman is brought to the hospital by her mother because she has "not been herself" for the past 3 months. The patient says she hears voices in her head. The mother said that when she is talking to her daughter she can’t seem to make out what she is saying; it is as if her thoughts are disorganized. When talking with the patient, you notice a lack of energy and an apathetic affect. Which of the following is the most likely diagnosis for this patient?

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

Answer: Schizophreniform disorder


Context: A 4-year-old girl is brought to the emergency department by her parents because of a painful rash of her hands and lower arms. According to the mother, she developed blisters and redness on her arms 2 days ago. Both parents claim there is no recent history of fever, itching, or trauma. Physical examination shows erythema and multiple fluid-filled bullae on the hands and arms up to the elbows with intermittent stripes of normal skin seen on the palmar aspect of the hand. The lesions are symmetrical in distribution and are sharply delineated. 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: Notify Child Protective Services


Context: A 53-year-old man is brought to the emergency department for confusion. He was in his usual state of health until about 3 hours ago when he tried to use his sandwich to turn off the TV. He also complained to his wife that he had a severe headache. Past medical history is notable for hypertension, which has been difficult to control on multiple medications. His temperature is 36.7°C (98°F), the pulse is 70/min, and the blood pressure is 206/132 mm Hg. On physical exam he is alert and oriented only to himself, repeating over and over that his head hurts. The physical exam is otherwise unremarkable and his neurologic exam is nonfocal. The noncontrast CT scan of the patient’s head is shown. Which of the following diagnostic tests is likely to reveal the diagnosis for this patient?

Question: Which of the following diagnostic tests is likely to reveal the diagnosis for this patient?

Answer: MRI of the brain