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Answer the following medical question with the correct letter choice:
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<<Question:>> A man is brought into the emergency department by the police department. The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless. On exam, the man is behaving erratically. His vitals are all within normal limits. He appears confused and has a slurred speech. On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds. Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2. His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7. His urinalysis is shown in Figure 1. Blood salicylate levels return as normal. While you await other diagnostic tests, which of the following should be administered next to treat this patient? ---- <<Choices:>> A) Ethanol B) Naltrexone C) Naloxone D) Fomepizole ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A medical research study is evaluating an investigational novel drug (medication 1) compared with standard therapy (medication 2) in patients presenting to the emergency department with myocardial infarction (MI). The study enrolled a total of 3,000 subjects, 1,500 in each study arm. Follow-up was conducted at 45 days post-MI. The following are the results of the trial: Endpoints Medication 1 Medication 2 P-Value Primary: death from cardiac causes 134 210 0.03 Secondary: hyperkalemia 57 70 0.4 What is the number needed to treat (NNT) for the primary endpoint of death from cardiac causes? (Round to the nearest whole number.) ---- <<Choices:>> A) 5 B) 16 C) 20 D) 50 ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 55-year-old man comes to the physician because of a 6-week history of tingling pain in the sole of his right foot when he raises it above chest level during exercises. He reports that he started exercising regularly 2 months ago and that his right calf cramps when he uses the incline feature on the treadmill, forcing him to take frequent breaks. The pain completely disappears after resting for a few minutes. He has an 8-year history of type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 34 years. His only medication is metformin. His pulse is 82/min, and blood pressure is 170/92 mm Hg. Straight leg raise test elicits pallor and tingling pain in the right foot. There is no pain in the back. His muscle strength is normal. Femoral pulses are palpable; right pedal pulses are absent. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Femoropopliteal artery stenosis B) Acute thrombosis of right popliteal vein C) Lumbar spinal stenosis D) Aortoiliac artery stenosis " ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 29-year-old primigravid woman at 35 weeks' gestation is admitted to the hospital in labor. She has no history of serious medical illness. She has had an uncomplicated pregnancy. Her last ultrasound at 22 weeks' gestation was normal. On admission, fetal heartbeats cannot be detected by fetal doppler monitor. Ultrasound shows decreased amniotic fluid levels and no evidence of fetal movement, respiration, or heart activity. The patient gives birth to a 2296 g (5 lb 1 oz) male infant. Physical examination shows no signs of life. There are no visible malformations. The placenta is unremarkable. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Perform karyotyping of amniotic fluid B) Recommend autopsy of the infant C) Obtain photographs, x-ray imaging, and MRI D) Obtain consent for parental genetic testing ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 67-year-old man is hospitalized after several days of fever and increasing shortness of breath. Respiratory viral panel returns positive for influenza A and the patient is started on a standard five day course of oseltamivir. Despite therapy, his shortness of breath continues to worsen and his oxygen saturation decreases to the point where ICU transfer and intubation are required. Chest radiograph shows bilateral infiltrates. Clinical criteria are consistent with development of Acute Respiratory Distress Syndrome (ARDS). After several weeks of supportive therapy, the patient improves with lung function returning to near normal. Which of the following processes is involved in the regeneration of alveolar lining after damage to alveoli occurs? ---- <<Choices:>> A) Sweeping of debris out of the alveoli by ciliated cells B) Excess mucus production by goblet cells C) Proliferation of surfactant-secreting cells D) Proliferation of club cells ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 65-year-old male is treated for anal carcinoma with therapy including external beam radiation. How does radiation affect cancer cells? ---- <<Choices:>> A) Induces the formation of thymidine dimers B) Induces the formation of disulfide bonds C) Induces deamination of cytosine D) Induces breaks in double-stranded DNA ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 56-year-old man with a history of hypertension presents to his physician with progressive fatigue and new onset muscle cramps. He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril, and amlodipine. His temperature is 98.0°F (36.7°C), blood pressure is 174/111 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient's cardiopulmonary and abdominal exams are unremarkable. Laboratory values are ordered as seen below. Serum: Na+: 138 mEq/L Cl-: 100 mEq/L K+: 3.3 mEq/L HCO3-: 33 mEq/L BUN: 20 mg/dL Glucose: 129 mg/dL What is the most likely underlying etiology of this patient's hypertension? ---- <<Choices:>> A) Aldosterone excess B) Catecholamine-secreting mass C) Cortisol excess D) Impaired kidney perfusion ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 65-year-old man comes to the physician because of a 1-week history of yellowish discoloration of his skin and generalized pruritus. Examination shows jaundice of the skin and scleral icterus. Urinalysis shows an elevated concentration of bilirubin and a low concentration of urobilinogen. Which of the following is the most likely underlying cause of these findings? ---- <<Choices:>> A) Absent UDP-glucuronosyltransferase activity B) Increased hemoglobin breakdown C) Increased intestinal bilirubin reabsorption D) Defective hepatic bile excretion ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 72-year-old woman is brought to the physician by her daughter because of a 6-month history of worsening short-term memory deficits and social withdrawal. Treatment with galantamine is initiated. Two weeks later, the patient develops vomiting, mild crampy abdominal pain, and watery, nonbloody diarrhea. Which of the following is the most appropriate pharmacotherapy? ---- <<Choices:>> A) Bethanechol B) Metoclopramide C) Atropine D) Oxybutynin ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 61-year-old man with schizophrenia in a locked inpatient psychiatry unit was observed making an unusual smacking motion with his lips, pursing his mouth, and blinking excessively. These symptoms started slowly about 2 weeks ago and have become more pronounced, but they do not seem to bother the patient. He resides in an inpatient psychiatric facility where he has been successfully treated with haloperidol for the past several months. His physical exam and vitals are within normal limits. Which of the following accurately describes his symptoms? ---- <<Choices:>> A) Tardive dyskinesia B) Acute dystonia C) Pseudoparkinsonism D) Palsy ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 17-year-old football player with no significant past medical history, social history, or family history presents to his pediatrician with itching in his groin. He says this started during summer workouts leading up to this season. He denies having any rash anywhere else on his body. The blood pressure is 123/78 mm Hg, pulse is 67/min, respiratory rate is 15/min, and temperature is 38.1°C (98.7°F). Physical examination reveals an erythematous, well-demarcated patch with peripheral scale on the left thigh, pubic region, and perineum. There is no apparent scrotal involvement with the rash. How can you confirm the suspected diagnosis? ---- <<Choices:>> A) KOH examination of lesion scrapings B) Nikolsky's sign on physical exam C) Gram stain of skin scrapings D) AFB stain of skin scrapings ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> An otherwise healthy 26-year-old man comes to the physician for medication counseling after recently being diagnosed with schizophrenia. Risperidone therapy is initiated. This patient is at increased risk for which of the following adverse effects? ---- <<Choices:>> A) Agranulocytosis B) Shortened QT interval C) Gynecomastia D) Weight loss ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 15-year-old woman presents with fever, altered mental status and a petechial rash on her lower extremities and back since yesterday evening. She also says she has been nauseous for the past 3 hours and has vomited twice. The patient mentions she has had heavy menstrual bleeding for the past few days. Her blood pressure is 95/80 mm Hg and her temperature is 40.0°C (104.0°F). On physical examination, the patient appears diaphoretic. A pelvic examination reveals a tampon in her vagina. Binding and activation of which of the following T cell receptors is responsible for this patient’s most likely condition? ---- <<Choices:>> A) B7 receptor B) Variable β-sequence of the T cell receptor C) CD3 D) IgCAM ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 2-year-old boy is brought to the physician for evaluation of pallor and increasing lethargy for 2 days. One week ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since subsided. The patient's father states that they returned early from a 6-week roadtrip in Mexico because of these symptoms. His parents have been giving him oral rehydration solution. His immunizations are up-to-date. He appears pale. His temperature is 38.4°C (101.1°F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm Hg. Examination shows scleral icterus. The abdomen is soft and nontender; there is no rebound or guarding. Bowel sounds are hyperactive. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 8.5 g/dL Mean corpuscular volume 94 μm3 Leukocyte count 18,000/mm3 Platelet count 45,000/mm3 Prothrombin time 12 sec Partial thromboplastin time 34 sec Serum Urea nitrogen 28 mg/dL Creatinine 1.6 mg/dL Bilirubin Total 2.5 mg/dL Direct 0.1 mg/dL Lactate dehydrogenase 1658 U/L A blood smear shows schistocytes. Which of the following is the most likely diagnosis?" ---- <<Choices:>> A) Henoch-Schönlein Purpura B) Thrombotic thrombocytopenic purpura C) Hemolytic uremic syndrome D) Immune thrombocytopenic purpura ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 17-year-old girl is referred by her dentist for a suspected eating disorder. She has been visiting the same dentist since childhood and for the past 2 years has had at least 2 visits for dental caries. She eventually admitted to him that she regularly induces vomiting by putting her fingers down her throat. She says she has been doing this for the last few years and purging at least once a week. More recently, she has been inducing emesis more often and even looked into diuretics as she feels that she is gaining more and more weight compared to her ‘skinny friends’. Her BMI is at the 50th percentile for her age and sex. Which of the following features is most consistent with this patient’s condition? ---- <<Choices:>> A) Patients with this disorder are not further sub-typed B) Patients do not usually initiate treatment C) Patients can have a history of both anorexia and bulimia D) Patients will typically have a BMI between 17–18.5 kg/m2 ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 14-year-old girl is brought to the physician by her father because of fever, chills, abdominal pain, and profuse non-bloody diarrhea. Her symptoms began one week ago, when she had several days of low-grade fever and constipation. She returned from Indonesia 2 weeks ago, where she spent the summer with her grandparents. Her temperature is 39.3°C (102.8°F). Examination shows diffuse abdominal tenderness and mild hepatosplenomegaly. There is a faint salmon-colored maculopapular rash on her trunk and abdomen. Which of the following is the most likely causal organism? ---- <<Choices:>> A) Giardia lamblia B) Schistosoma mansoni C) Salmonella typhi D) Clostridium perfringens ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 22-year-old female college student is treated with metronidazole after presenting to student health services with itching, discharge, and pain in her vagina. At a party shortly afterward she experiences facial flushing, nausea, tachycardia, dyspnea, headache, and abdominal cramps after consuming alcohol. Serum levels of which of the following are likely elevated in this patient following alcohol consumption: ---- <<Choices:>> A) Acetaldehyde B) Uric acid C) Cytochrome P-450 enzymes D) Amylase ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 23-year-old primigravida presents for a regular prenatal care visit at 16 weeks gestation. She complains of increased fatigability, but is otherwise well. She takes folic acid, iron, and vitamin D supplementation. Her vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 86/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉). The physical examination is unremarkable. The complete blood count results are as below: Erythrocyte count 3.9 million/mm3 Hb 11.1 g/dL HCT 32% Reticulocyte count 0.2% MCV 90 fL Platelet count 210,000/mm3 Leukocyte count 8,100/mm3 Which of the following tests is required to investigate the cause of the patient’s laboratory findings? ---- <<Choices:>> A) Serum iron level B) Serum B12 level C) Transferrin D) No tests required ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> An 80-year-old man is transferred from a step-down unit to a med-surg floor in the hospital. He had undergone a successful hernia surgery 14 hours ago. Before the surgery, he was pre-treated with atropine, scopolamine, and morphine and recovered well in the PACU after the surgery. There were no complications in the step-down unit and the patient continued to recover. On the med-surg floor, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, the blood pressure is 100/75 mm Hg, the oxygen saturation is 90%. On physical exam, he is a well-developed, obese man. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. His incision site is clean, dry, and intact with an appropriate level of swelling and erythema. During the physical, the patient mentions some discomfort in his abdomen and pelvis and during a records review it is noted that he has not passed urine in the PACU, step-down unit, or since arriving on the med-surg floor. A bladder scan is inconclusive due to body habitus. What is the next best step in the treatment of this patient? ---- <<Choices:>> A) Insert a ‘straight cath’ into the patient’s bladder B) Aggressive IV fluids C) Digital rectal exam D) Renal ultrasound ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A healthy 19-year-old man presents to his primary care provider complaining of painless “blisters” in his mouth. He reports that he noticed a white film on his tongue and the sides of his mouth 2 days ago while brushing his teeth. The film was easily brushed off. He also complains of a bitter metallic taste in his mouth but otherwise denies pain, burning, dysphagia, or hoarseness. He is otherwise healthy and takes no medications. He is a competitive swimmer and has had 8 sexual partners in the past year. He intermittently uses barrier protection. On exam, he is well-appearing and in no acute distress. His oral examination demonstrates patches of white pseudomembranes that can be wiped away to reveal erythematous mucosa. A medication with which of the following mechanisms of action is most appropriate in this patient? ---- <<Choices:>> A) Disruption of cell membrane permeability B) Disruption of microtubule formation C) Inhibition of 14-alpha-demethylase D) Inhibition of beta-glucan synthase ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 56-year-old man presents to the clinic complaining of subacute back pain for the past month. The pain is described as a dull, constant ache that is worse at night. He could not recall any precipitating event except for an amateur weight-lifting competition that he participated in 2 months ago. Past medical history is significant for non-small cell lung cancer that was diagnosed and successfully treated. A PET scan 1 year ago demonstrated no recurrence. Physical exam was unremarkable except for some point tenderness along the lumbosacral area. What is the most likely imaging finding in this patient? ---- <<Choices:>> A) Bulging disc impinging on lumbar spinal nerve B) Lytic lesions of the lumbar spine C) Narrowing of the lumbar disc space D) Sacroilitis and fusion of the lumbar spine ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 4-year-old boy is brought to the emergency department because of severe abdominal pain and bilious vomiting for 6 hours. He has not had bowel movements in the past 24 hours. He appears ill. His temperature is 37.8°C (100°F) and pulse is 122/min. Examination shows a distended abdomen. There is tenderness to palpation in the lower abdomen; guarding and rebound tenderness are present. Bowel sounds are decreased. An x-ray of the abdomen shows dilated loops of bowel. He has been accompanied by his 14-year-old brother. The surgeon recommends an emergency laparotomy. The parents are away visiting friends and cannot be reached. Which of the following is the most appropriate next best step in management? ---- <<Choices:>> A) Get consent from the patient's brother B) Get consent from the patient C) Perform emergency laparotomy D) Delay surgery until parental consent ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 3-week-old male newborn is brought to the hospital because of poor weight gain since birth. He was born at 38 weeks' gestation via normal vaginal delivery. He weighed 3005 g (6 lb, 10 oz) at birth and currently weighs 2835 g (6 lb, 4 oz). He has been latching on and breastfeeding well since birth. His mother has a history of Graves' disease and underwent near-total thyroidectomy in the second trimester of her pregnancy after her symptoms could not be controlled with antithyroid drugs. She is currently receiving L-thyroxine therapy. The patient's temperature is 38.9°C (102°F), pulse is 176/min, and respirations are 42/min. He appears irritable. Examination shows a diaphoretic infant with a paucity of subcutaneous fat. There is swelling of the neck at the midline. Which of the following is the most likely cause? ---- <<Choices:>> A) Transplacental passage of thyroid peroxidase antibodies B) Transplacental passage of TSH receptor antibodies C) Transplacental viral infection D) Opiate use in the mother ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 57-year-old female with a past medical history of alcoholism presents to the emergency room vomiting bright red blood. She is accompanied by her partner, who reports that she had been complaining of black and tarry stools for the past several days. Vital signs are temperature 37 degrees celsius, heart rate 141 beats per minute, blood pressure 90/60, respiratory rate 20, and oxygen saturation 99% on room air. On physical examination, she has splenomegaly and a positive fluid wave. The remainder of her examination is within normal limits. The patient is stabilized with intravenous fluids, and her blood pressure improves. Subsequent emergent upper endoscopy reveals bleeding from the submucosal veins in the lower 1/3 of the esophagus, but no gastric bleed. In the endoscopy suite she also receives IV octreotide. After intervention and resolution of her acute bleed, which of the following pharmacologic agents is indicated? ---- <<Choices:>> A) Phentolamine B) Prazosin C) Nifedipine D) Nadalol ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 65-year-old man with a history of hypertension, obesity, and alcoholic cirrhosis is seen in clinic for follow-up. He feels well and currently drinks 5 glasses of wine each night. Medications include atenolol and lisinopril. On physical exam, temperature is 98.1 deg F (36.7 deg C), blood pressure is 151/82 mmHg, pulse is 71/min, and respirations are 14/min. He has spider angiomata on his chest; no asterixis, jaundice, ascites, or peripheral edema is noted. Screening ultrasound reveals a new liver nodule, and follow up CT demonstrates a 2 cm right hepatic lobe lesion with enhancement in the arterial phase. No hypodense attenuation is seen on the venous or delayed phase. What is the next step in management? ---- <<Choices:>> A) Proceed with liver biopsy B) Refer for surgical resection C) Refer for radiofrequency ablation D) Observe and get follow-up imaging in 3 months ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 66-year-old man is brought to the emergency room by his wife due to abdominal distension and persistent somnolence for the past 2 weeks. The patient’s wife says that he has been sleeping much more than usual for the past 5 days. His bowel and bladder habit have not changed. His past medical history is significant for alcoholic liver cirrhosis. His vital signs include: pulse 76/min, respiratory rate 15/min, temperature 38.0°C (100.4°F) and blood pressure 122/75 mm Hg. On physical examination, the patient is altered and not responsive to commands. Oriented x 0. The abdomen is significantly distended. Shifting dullness is present and a positive fluid wave can be elicited. Hyperreflexia and asterixis are noted. Laboratory findings are significant for the following: Laboratory test Sodium 140 mEq/L Potassium 3.5 mEq/L Chloride 97 mEq/L Glucose 90 mg/dL Ammonia 100 µg/dL (ref: 19-60 µg/dL) Arterial blood gas pH 7.4 pCO2 40 mm Hg pO2 90 mm Hg HCO3 26 mEq/L An abdominal ultrasound shows surface nodularity compatible with cirrhosis but no other changes aside from ascites. An upper GI endoscopy is performed which shows gastric varices with no signs of active bleeding. An MRI of the brain is insignificant. What is the most likely precipitating factor that led to this patient’s condition? ---- <<Choices:>> A) Spontaneous bacterial peritonitis B) Metabolic alkalosis C) Portal vein thrombosis D) Hypoglycemia ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 27-year-old man presents to the emergency department after a motor vehicle collision. The patient was the front seat unrestrained driver in a head on collision. The patient’s echocardiogram (ECG) is notable only for sinus tachycardia. His temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is given 2 liters of Ringer lactate solution and morphine. Initial workup demonstrates that the patient’s pulmonary capillary wedge pressure and troponins are elevated. The patient is currently complaining of chest pain. Physical exam is notable for an uncomfortable young man with bruising over his chest wall. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Cardiac contusion B) Hemorrhage C) Pulmonary contusion D) Takotsubo cardiomyopathy ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 56-year-old man presents to the emergency department for progressively worsening fatigue, malaise, fever, and abdominal pain. He reports that his symptoms began approximately 1 week ago and he has noticed episodes of diarrhea. He recently started melatonin and magnesium supplementation in hopes of improving his sleep. Medical history is significant for alcohol use disorder that required multiple hospital admissions for management of acute pancreatitis and cirrhosis. He states that he occasionally injects heroin intravenously. Temperature is 100°F (37.8°C), blood pressure is 105/70 mmHg, pulse is 92/min, and respirations are 17/min. Physical examination is significant for scleral icterus, hepatomegaly, ascites, and diffuse abdominal tenderness. Laboratory testing is significant for leukocytosis and metabolic acidosis. A paracentesis is performed and he is admitted into the hospital to receive intravenous cefotaxime and albumin. Ascitic fluid analysis demonstrates a polymorphonuclear cell count of 280 cells/mm^3, serum-ascites albumin gradient of 1.3 g/dL, and a culture positive for Escherichia coli sensitive to cefotaxime and ceftriaxone. On hospital day 2, the nurse reports that the patient is oliguric in the setting of constant fluid intake. Physical examination is unchanged. Laboratory testing is significant for a serum sodium of 131 mEq/L and creatinine of 1.8 mg/dL (it was 0.9 mg/dL on admission). Urine studies are significant for a low urine sodium level, without evidence of blood or protein. Since the hospital admission, he has not been started on any new medications. Which of the following will be the best treatment option for this patient? ---- <<Choices:>> A) Adding dopamine to his treatment regimen B) Adding lisinopril to his treatment regimen C) Liver transplantation D) Transjugular intrahepatic portosystemic shunting ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 29-year-old woman presents to the clinic after several months of weight loss. She noticed a 6.8 kg (15 lb) unintentional weight loss over the preceding several months. She has not changed her diet or exercise habits. She also reports feuding with her boyfriend over the temperature of their shared apartment, as she always feels warmer than he does. The vital signs include: heart rate 110/min and blood pressure 146/78 mm Hg. The physical exam is notable for warm and slightly moist skin. She also exhibits a fine tremor in her hands when her arms are outstretched. The urine pregnancy test is negative. Which of the following is the best single treatment option for this patient? ---- <<Choices:>> A) Glucocorticoids B) Methimazole C) Propranolol D) Radioiodine therapy ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 21-year-old man comes to the physician because of pruritus and a hypopigmented rash on his upper body for 5 days. He first noticed the symptoms after returning from a business trip last week in the Bahamas. While he was there, he visited a couple of beaches and went hiking with some coworkers. The rash initially started as a single lesion on his upper back but since then has extended to his shoulders. He has a history of type 1 diabetes mellitus controlled with an insulin pump. He works as an office manager and has no known exposure to melanocytotoxic chemicals. He has been sexually active with three female partners over the past year and uses condoms inconsistently. He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 23.9 kg/m2. His temperature is 37.2°C (99°F), pulse is 78/min, and blood pressure is 130/84 mm Hg. A photograph of the rash is shown. One month ago, his hemoglobin A1C was 7.8%. Which of the following is most likely to confirm the diagnosis? ---- <<Choices:>> A) Wood lamp examination B) Skin culture C) Potassium hydroxide preparation D) Skin biopsy ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 5-year-old female is brought to a speech therapist for continuing work on improving her communication skills. She is only able to verbalize two word sentences and has generalized developmental delay. When she was born it was noticed that she had a high pitched mewing cry and subsequent physical exam revealed microcephaly, prominent epicanthal folds, and a holosystolic murmur best heard in the left 5th intercostal space near the sternum. An abnormality of which of the following chromosomes is most likely responsible for this patient's disorder? ---- <<Choices:>> A) 5 B) 7 C) 18 D) 21 ---- <<Answer:>>
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A
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<<Question:>> A 62-year old female comes to the physician because of vaginal spotting and urinary urgency for the past 4 days. She has had no fever, abdominal pain, or diarrhea. Menopause occurred at 52 years of age. Her last Pap smear 1 year ago was normal. She has hypertension, hypercholesterolemia, and diabetes. Medications include atorvastatin, hydrochlorothiazide, metformin, and aspirin. She is sexually active with her husband. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 12/min, and blood pressure is 155/65 mm Hg. Pelvic exam demonstrates a 4 x 3 cm firm, immobile erythematous mass on the right inner vaginal wall. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Pap smear B) Biopsy of the mass C) Incision and drainage D) Urine gonorrhea and chlamydia testing ---- <<Answer:>>
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B
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<<Question:>> A 59-year-old man is evaluated for progressive joint pain. There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands. His hand radiograph is shown. He has had diabetes mellitus for 2 years which is not well controlled with medications. Lab studies show a transferrin saturation of 88% and serum ferritin of 1,200 ng/mL. Which of the following best represents the etiology of this patient condition? ---- <<Choices:>> A) Deposition of urate crystals B) Deposition of calcium pyrophosphate (CPP) crystals C) Inflammatory rheumatological syndrome D) Pathogenic inoculation of microbes ---- <<Answer:>>
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B
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<<Question:>> A newborn is found to be extremely cyanotic immediately after birth. He then develops progressive respiratory failure and is admitted to the neonatal ICU. A single loud S2 heart sound is appreciated as well as a machine-like murmur at the left upper sternal border. Radiography shows an enlarged "egg-shaped" heart. The newborn is then taken for a atrial septostomy to alleviate the condition pending definitive surgical correction. Which of the following is the most likely cause of this newborn's condition? ---- <<Choices:>> A) Coarctation of the aorta B) Persistent truncus arteriosus C) Transposition of great vessels D) Tricuspid atresia ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 25-year-old male involved in a knife fight presents with a penetrating wound to the chest. The patient is unconscious and cannot provide any further history. Vitals show a temperature of 37-0°C (98.6°F), blood pressure of 85/55 mm Hg, pulse of 115/min, respirations of 19/min, and oxygen saturation of 92% on room air. On physical examination, the patient is diaphoretic and unresponsive. Extremities are pale and cool. There is a 3-inch long penetrating wound between the 3rd and 4th intercostal space on the left side of the chest, which is bleeding profusely. Transthoracic echocardiography reveals a full thickness penetrating injury to the right ventricular free wall. There are no apparent injuries to any coronary arteries or major branches. The patient is intubated and aggressive fluid resuscitation is initiated, including a blood transfusion. Which of the following is the best definitive surgical approach to take in this patient? ---- <<Choices:>> A) Immediate cardiac transplant B) Watchful waiting while resuscitative fluids are initiated C) Interrupted 2-0 polypropylene suture with supporting pledgets D) Needle thoracostomy over the 2nd intercostal space ---- <<Answer:>>
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C
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<<Question:>> A post-mortem lung examination of a 68-year-old male overweight male with evidence of chronic lower extremity edema, a 60 pack-year smoking history and daily productive cough would be most likely to reveal: ---- <<Choices:>> A) Hypereosinophilia B) Reid Index > 50% C) Non-caseating granulomas D) Evidence of a necrotizing infection ---- <<Answer:>>
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B
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<<Question:>> A 54-year-old male makes an appointment with his primary care physician due to chronic fatigue that has left him unable to hike or do other physically demanding activities with his friends. He has well-controlled hypertension and diabetes but has otherwise been healthy. He does not smoke but drinks socially with his friends. Physical exam reveals enlarged nodules that are not tender to palpation. A biopsy is obtained showing a characteristic change in chromosome 18. The regulation of which of the following proteins will be most abnormal in this patient? ---- <<Choices:>> A) Caspase-9 B) CD15 C) Cyclin-dependent kinase 4 D) Ras pathway transcription factors ---- <<Answer:>>
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A
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<<Question:>> A 44-year-old African-American woman comes to the physician for a routine examination. She is concerned about cancer because her uncle died of metastatic melanoma 1 year ago. She has no history of serious illness and does not take any medication. She has been working in a law firm for the past 20 years and travels to the Carribean regularly with her husband. Examination of her skin shows no abnormal moles or warts. This woman is at greatest risk of which of the following types of melanoma? ---- <<Choices:>> A) Desmoplastic B) Nodular C) Acral lentiginous D) Superficial spreading ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 60-year-old woman is brought to the clinic by her daughter for evaluation. The daughter reports that her mother has recently been having difficulty combing her hair in the mornings. The patient’s family history is significant for an ischemic stroke in her father. The patient’s past medical history is positive for diverticulosis. She takes no medication. Her blood pressure is 120/70 mm Hg, heart rate is 75/min, respiratory rate is 14/min, and temperature is 37.6°C (99.7°F). On physical examination, the patient’s neck is stiff and she also has bilateral shoulder tenderness; muscle strength is intact. Laboratory work is performed and presented below: Hemoglobin 12.9 g/dL Hematocrit 37.7% Leukocyte count 5,500/mm3 Neutrophils 65% Lymphocytes 30% Monocytes 5% Mean corpuscular volume 82.2 μm3 Platelet count 190,000/mm3 Erythrocyte sedimentation rate 65 mm/h C-reactive protein 44 mg/dL For which of the symptoms below should the patient be screened? ---- <<Choices:>> A) Jaw claudication B) Heliotrope rash C) Gastroesophageal reflux D) Pink plaques with silvery scales ---- <<Answer:>>
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A
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<<Question:>> A 30-year-old woman comes to the physician because she has been unable to conceive for 3 years. Analysis of her husband's semen has shown normal sperm counts during this time. The patient also reports episodic pelvic and back pain accompanied by painful diarrhea for 5 years. She has about one such episode on average per month for 4–6 days. She has taken ibuprofen for the pain, which has provided some relief. Menses have occurred at regular 29-day intervals since menarche at the age of 14 years and last for 7 days. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic and bimanual examinations are normal; rectal examination is unremarkable. A hysterosalpingogram 6 months prior showed normal results. Which of the following is the most likely underlying mechanism of this patient's symptoms? ---- <<Choices:>> A) Loss of fallopian tube function following infection B) Smooth muscle tumor arising from the myometrium C) Endometrial tissue outside the uterine cavity D) Increased secretion of androgens and luteinizing hormone ---- <<Answer:>>
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C
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<<Question:>> A 55-year-old truck driver is brought to a physician by his wife. She states that her husband developed a fever and began feeling weak 3 days ago, but has refused medical help. He has been unable to go to work because of his symptoms. The patient has been previously hospitalized for a tricuspid valve replacement surgery 1 year ago and takes aspirin daily. The medical history is also relevant for myocardial infarction 3 years ago and hypertension for the past 10 years, for which he takes lisinopril. His blood pressure is 140/80 mm Hg, the pulse is 82/min, the respirations are 18/minute, and the temperature is 37.2°C (98.9°F). On examination, several hemorrhages are noted on the nail beds of several fingers. Which of the following findings would be most helpful in establishing a diagnosis? ---- <<Choices:>> A) Bicuspid valve B) Friable irregular masses attached to the valve C) Papillary muscle rupture D) Annular calcification ---- <<Answer:>>
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B
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<<Question:>> A previously healthy 30-year-old woman comes to the physician for the evaluation of pain during sexual intercourse for 6 months. She also reports frequent episodes of crampy pelvic pain that starts one day before menses and lasts for 7 days. Her symptoms are not relieved with pain medication. Menses occur at regular 28-day intervals and last 5 days. Her last menstrual period was 2 weeks ago. She is sexually active with her husband. She uses a combined oral contraceptive pill. Her vital signs are within normal limits. Physical examination shows rectovaginal tenderness. Cervical and urethral swabs are negative. Transvaginal ultrasonography shows no abnormalities. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Measurement of CA-125 levels B) Hysterectomy C) Laparoscopy D) Hysteroscopy ---- <<Answer:>>
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C
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<<Question:>> A 50-year-old man visits his physician after 20 years of not seeking any medical care. He is concerned about his health after a colleague recently had a heart attack. The patient has no active complaints and says he feels healthy; however, he does not exercise regularly and lives a sedentary lifestyle. He is employed as an administrative position at a local college, and is seated at a desk most of the day. His father had a heart attack at age 54 and his mother is still alive with no health concerns. He does not smoke, only drinks socially, and does not use drugs. Today, his blood pressure is 130/90 mm Hg, pulse is 84/min, and respiratory rate is 14/min. Physical examination reveals an obese male with no significant findings. An ECG shows no abnormalities, and laboratory testing shows the following: Laboratory test Serum glucose (fasting) 105 mg/dL Serum electrolytes Sodium 142 mEq/L Potassium 3.9 mEq/L Chloride 101 mEq/L Serum creatinine 0.8 mg/dl Blood urea nitrogen 10 mg/dl Cholesterol, total 250 mg/dL HDL-cholesterol 35 mg/dL LDL-cholesterol 186 mg/dL Triglycerides 170 mg/dL Urinalysis Glucose negative Ketones negative Leucocytes negative Nitrites negative Red blood cells (RBC) negative Casts negative Which of the following lab abnormalities in this patient is an indication for treatment? ---- <<Choices:>> A) Blood pressure reading B) Patient’s weight C) High LDL-cholesterol D) Serum glucose level ---- <<Answer:>>
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C
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<<Question:>> A 26-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision in which she was a restrained passenger. On arrival, she is lethargic and incoherent. She has severe facial lacerations and is in respiratory distress. Her pulse is 130/min, respirations are 29/min, and blood pressure is 90/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 70%. Examination shows multiple facial lacerations. There is dullness to percussion and decreased breath sounds over the left lung base. Abdominal examination shows diffuse tenderness with no guarding or rebound. Bowel sounds are normal. The remainder of the examination shows no abnormalities. Her hemoglobin concentration is 12.1 g/dL. An x-ray of the chest shows a fractured left second rib, depression of the left mainstem bronchus, deviation of the nasogastric tube to the right, and a widened mediastinum. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Diaphragmatic rupture B) Traumatic bronchial rupture C) Thoracic aortic rupture D) Tension pneumothorax ---- <<Answer:>>
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C
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<<Question:>> A 26-year-old G1P0 woman presents to her primary care physician’s office with feelings of anxiety and trouble with sleep. She finds it difficult initiating sleep, occasionally has palpitations, and feels fatigued. She denies having similar symptoms in the past or starting any new medications or illicit drugs. She is currently 10 weeks pregnant and is closely followed by her obstetrician. Her temperature is 98.6°F (37°C), blood pressure is 125/70 mmHg, pulse is 105/min, and respirations are 18/min. On physical exam, the patient is mildly diaphoretic. The skin is warm and the thyroid gland is diffusely enlarged with thyroid bruits. Laboratory studies are significant for a thyroid-stimulating hormone level of 0.01 µU/mL (normal is 0.5-5.0 µU/mL) and an elevated free thyroxine (FT4) that is inappropriate for her pregnancy. Which of the following is the best treatment option for this patient? ---- <<Choices:>> A) Methimazole B) Propylthiouracil C) Radioiodine therapy D) Thyroidectomy ---- <<Answer:>>
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B
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<<Question:>> A 32-year-old woman comes to the physician because of a 3-week history of intermittent loose stools and a 1.2-kg (2.6-lb) weight loss. She immigrated to the US from Uganda 6 weeks ago. Abdominal examination shows diffuse tenderness with no guarding or rebound. The liver is firm and palpable 3 cm below the right costal margin, and the spleen is palpable just below the left costal margin. Her leukocyte count is 12,800/mm3 (12% eosinophils). Stool culture shows several oval-shaped eggs with lateral spines. Microscopic examination of a liver biopsy specimen shows granulomatous inflammation with periportal fibrosis. Exposure to which of the following is most likely to have played a role in the development of this patient's symptoms? ---- <<Choices:>> A) Undercooked pork meat B) Undercooked fish meat C) Dog feces D) Freshwater snails ---- <<Answer:>>
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D
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<<Question:>> A 3-month-old girl is brought to a pediatrician by her parents. She has central cyanosis without signs of respiratory distress or signs of heart failure. An echocardiogram reveals severe pulmonary outflow obstruction, right ventricular hypertrophy, a ventricular septal defect, and an overriding of the aorta. An elective primary surgical repair is planned at 4 months of age. Which of the following statements is true about this girl’s condition? ---- <<Choices:>> A) The tricuspid valve is the most common valve affected by bacterial endocarditis in uncorrected tetralogy of Fallot. B) Normal hemoglobin in patients with tetralogy of Fallot does not rule out iron deficiency anemia. C) Cerebral arterial thrombosis is more common than cerebral venous thrombosis. D) Refractory heart failure is a common complication of tetralogy of Fallot. ---- <<Answer:>>
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B
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<<Question:>> Six days after undergoing surgical repair of a hip fracture, a previously healthy 79-year-old woman is agitated and confused. She is unarousable during the day, but then is awake and impulsive during the night, requiring frequent reorientation. Her husband says that she usually drinks one to two glasses of wine weekly. Her only current medication is oxycodone for pain. Her vital signs are within normal limits. She is distressed and oriented to person but not to place or time. Neurologic examination shows inattentiveness but no focal deficits. Urine dipstick is normal. Which of the following is the most likely cause of her current condition? ---- <<Choices:>> A) Dementia B) Opioid intoxication C) Delirium D) Urinary tract infection ---- <<Answer:>>
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C
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<<Question:>> A 54-year-old woman with a past medical history of mental retardation, hypertension, and diabetes presents to the emergency department with a change in her behavior. Her caretakers state that the patient’s gait suddenly became ataxic, and she became less responsive than her normal non-verbal baseline. Her temperature is 98.5°F (36.9°C), blood pressure is 125/68 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for an unremarkable HEENT exam with normal facial features and no signs of airway compromise. Neurological exam is remarkable for new onset spasticity. The patient has 3+ reflexes and a positive Babinski sign. Musculoskeletal exam is only notable for symmetric swelling and deformities of the patient’s hands bilaterally. Additionally, there is a "clunk" when posterior force is applied to the head while anterior force is applied to the cervical spine. Which of the following is the most likely risk factor that predisposed this patient to this condition? ---- <<Choices:>> A) Cerebral palsy B) Diabetes mellitus C) Down syndrome D) Rheumatoid arthritis ---- <<Answer:>>
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D
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<<Question:>> A 24-year-old man is brought to the emergency department 15 minutes after he sustained a stab wound to the left chest just below the clavicle. On arrival, he has rapid, shallow breathing and appears anxious. His pulse is 135/min, respirations are 30/min and shallow, and palpable systolic blood pressure is 80 mm Hg. He is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Five minutes later, his pulse is 133/min and blood pressure is 82/45 mm Hg. Examination shows no active external bleeding. There is a 2.5-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line. Cardiovascular examination shows muffled heart sounds and jugular venous distention. Breath sounds are normal. Further evaluation of this patient is most likely to show which of the following findings? ---- <<Choices:>> A) Tracheal deviation toward the right side B) Hemoptysis C) A drop in systolic blood pressure of 14 mmHg during inspiration D) Paradoxical motion of part of the chest with breathing " ---- <<Answer:>>
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C
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<<Question:>> A 40-year-old man presents to his primary-care doctor for a follow-up of his hypertension. He is asymptomatic at his office visit and denies any new complaints. He has a 10-year history of hypertension that remains poorly controlled on maximum doses of lisinopril, hydrochlorothiazide, and amlodipine. His past medical history is otherwise unremarkable. He has no smoking history, drinks alcohol occasionally, and denies any illicit drug use. His father required a kidney transplant in his forties. The physical exam is notable for palpable flank masses bilaterally. Laboratory studies show a creatinine of 2.5. The physician orders a renal ultrasound, and the results are shown. Which of the following is the most appropriate test to screen for additional complications of this patient's condition? ---- <<Choices:>> A) Colonoscopy B) Esophagogastroduodenoscopy C) Liver function tests D) MR angiography of the brain ---- <<Answer:>>
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D
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<<Question:>> A 17-year-old female is brought to the emergency room by her father because she has been experiencing shortness of breath and chest pain. She says that the chest pain is worse when she breathes or coughs. Furthermore, on the way to the hospital she noticed that there were specks of blood on a tissue that she coughed into. She has no previous medical history and does not recall anything that could have provoked these symptoms. On presentation her temperature is 99°F (37.2°C), blood pressure is 107/65 mmHg, pulse is 102/min, respirations are 21/min, and O2 saturation is 91% on room air. Further testing shows a large filling defect in the pulmonary vessels, and the patient is started on an appropriate treatment intravenously. After drug administration, the effects of the drug are monitored using a standard blood test. Surprisingly, the test results come back within normal parameters. The most likely underlying cause of this patient's symptoms has which of the following modes of inheritance? ---- <<Choices:>> A) Autosomal dominant B) Autosomal partial dominance C) X-linked dominant D) X-linked recessive ---- <<Answer:>>
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A
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<<Question:>> A 26-year-old male presents to his primary care physician with complaints of burning with urination, penile discharge, and intermittent fevers. A urethral smear shows gram negative diplococci within white blood cells. The organism grows well when cultured on Thayer-Martin agar. The patient is prescribed a course of ceftriaxone and the infection resolves without further complication. One year later, the patient returns with the same infection. Which of the following best explains this lack of lasting immunity? ---- <<Choices:>> A) Exotoxin release B) Antigenic variation C) Polysaccharide capsule D) Bruton's agammaglobulinemia ---- <<Answer:>>
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B
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<<Question:>> A 37-year-old man with no significant past medical history is rear-ended in a motor vehicle accident. He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities. His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%. What is the most appropriate next step upon presentation to the emergency room? ---- <<Choices:>> A) Lateral cervical film B) Cervical immobilization C) IV methylprednisolone D) Observation overnight ---- <<Answer:>>
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B
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<<Question:>> A 43-year-old man with a history of schizophrenia, currently controlled with medication, comes in for an appointment with his internist. He is concerned about abnormal discharge from both nipples over the past 3 months. The fluid is white, and he wonders if it could be milk. On further review of systems, he endorses a diminished sexual drive. The physician suspects that one of the patient's medications may be the culprit for these symptoms. Which of the following medications is NOT likely to be the cause? ---- <<Choices:>> A) Haloperidol B) Bromocriptine C) Fluphenazine D) Risperidone ---- <<Answer:>>
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B
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<<Question:>> A 2-day-old male newborn is brought to the physician because of yellowing of the skin and sclerae for 16 hours. He had previously been well. He was born at 38 weeks' gestation via uncomplicated vaginal delivery and weighed 3.1 kg (6 lb 13 oz). The mother has no medical insurance and did not receive prenatal care. The newborn's 4-year-old brother has sickle cell disease. Examination shows jaundice. The abdomen is mildly distended. The liver is palpated 1 cm below the right costal margin and the spleen tip is palpated just below the left costal margin. Laboratory studies show: Hemoglobin 11 g/dL Reticulocytes 9% Leukocytes 9,100/mm3 Platelets 244,000/mm3 Maternal blood group 0, Rh-negative Anti-Rh antibody titer positive Fetal blood group B, Rh-negative Serum Bilirubin, total 11.3 mg/dL Direct 0.3 mg/dL Which of the following is the most likely cause of this patient's condition?" ---- <<Choices:>> A) RBC sickling B) Anti-D antibodies C) Biliary duct malformation D) Anti-B antibodies ---- <<Answer:>>
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D
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<<Question:>> A 65-year old man presents with gradually worsening rigidity of his arms and legs and slowness in performing tasks. He says he has also noticed hand tremors, which increase at rest and decrease with focused movements. On examination, the patient does not swing his arms while walking and has a shortened, shuffling gait. An antiviral drug is prescribed which alleviates the patient’s symptoms. Which of the following drugs was most likely prescribed to this patient? ---- <<Choices:>> A) Amantadine B) Ribavirin C) Levodopa D) Zidovudine ---- <<Answer:>>
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A
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<<Question:>> The patient is given prophylactic labetalol and magnesium sulfate. Examination shows absent deep tendon reflexes bilaterally. Which of the following is the most appropriate next step in the management of this patient? ---- <<Choices:>> A) Stop magnesium sulfate and give calcium gluconate B) Stop labetalol C) Stop magnesium sulfate and give lorazepam D) Perform nerve conduction studies ---- <<Answer:>>
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A
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<<Question:>> A 75-year-old woman is brought by a patrolman to the emergency department because of altered mental status. She was found wandering next to the highway. The patient was unable to answer questions and collapsed in transit. Her vitals are: temperature, 33.0°C (91.4°F); pulse, 40/min; respirations,12/min; blood pressure, 80/50 mm Hg; and oxygen saturation, 85% on room air. Physical examination shows decorticate posturing, incomprehensible speech, eyes opening to pain, dry hair, coarse and waxy skin, and non-pitting edema around the face and all extremities. Electrocardiogram shows sinus bradycardia. Laboratory studies show: Calcium 9.0 mg/dL Hematocrit (female) 34% Potassium 4.0 mEq/L Sodium 120 mEq/L TSH 110.0 µU/mL Thyroxine (T4) 1.2 µg/dL Triiodothyronine (T3) 70 ng/dL Which of the following is the most likely diagnosis in this patient? ---- <<Choices:>> A) Myxedema coma B) Pheochromocytoma crisis C) Septic shock D) Tertiary hyperparathyroidism ---- <<Answer:>>
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A
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<<Question:>> A 66-year-old male presents to his primary care physician to discuss his increasing shortness of breathover the last 3 months. He notes that this is particularly obvious when he is mowing his lawn or climbing the stairs in his home. His past medical history is significant for hypertension that is well-controlled with lisinopril. His vital signs are as follows: T 37.6 C, HR 88, BP 136/58, RR 18, SpO2 97% RA. Physical examination is significant for an early diastolic blowing, decrescendo murmur heard best at the left sternal border, a midsystolic murmur heard best at the right upper sternal border, and a late diastolic rumbling murmur heard best at the apex on auscultation. In addition, an S3 heart sound is also present. Bounding pulses are palpated at the radial arteries bilaterally. Which of the following diagnoses is most likely in this patient? ---- <<Choices:>> A) Mitral regurgitation B) Aortic regurgitation C) Aortic stenosis D) Mitral prolapse ---- <<Answer:>>
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B
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<<Question:>> A 28-year-old woman presents following a suicide attempt 2 days ago. She says that her attempt was a result of a fight with her boyfriend and that she slit her wrists in an attempt to keep him from breaking up with her. In the past, she has had many turbulent relationships, both romantic and in her family life. Her family members describe her as being very impulsive and frequently acting to manipulate people’s feelings. Since she was admitted to the hospital, she has spit at several staff members and alternated between sobbing and anger. She has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. Which of the following is the most likely diagnosis in this patient? ---- <<Choices:>> A) Histrionic personality disorder B) Borderline personality disorder C) Dependent personality disorder D) Narcissistic personality disorder ---- <<Answer:>>
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B
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<<Question:>> A 50-year-old man presents to his primary care doctor following an inguinal hernia repair. The patient reports no pain in his lower abdomen or groin, no constipation, and states that he enjoys his usual diet. He denies any use of alcohol, tobacco, or illicit drugs. He has returned to work as a cruise ship attendant. Preoperative workup included chest radiography which demonstrated an opacification in his right middle lobe. The patient agrees to undergo computed tomography (CT) of his chest without contrast for further evaluation. The radiologist reports an 8 mm nodule in the patient's peripheral right middle lobe that has regular margins and appears calcified. One year later, the patient obtains another chest CT without contrast that reports the nodule size as 10 mm with similar characteristics. What is the most appropriate next step in management? ---- <<Choices:>> A) CT chest without contrast in 24 months B) Positive emission tomography (PET) of chest now C) Right middle lobectomy now D) Bronchoscopy-guided biopsy now ---- <<Answer:>>
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B
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<<Question:>> A 29-year-old man comes in for evaluation of infertility. He has been trying to conceive for over 2 years with his wife and previous evaluation of his wife's fertility revealed no abnormalities. Physical exam reveals a tall man with long extremities, sparse body hair, gynecomastia, and small testes. Laboratory studies reveal increased serum follicle-stimulating hormone concentration and an increased estradiol:testosterone ratio. Genetic studies reveal a cytogenetic abnormality. If this abnormality was inherited from the patient's father, at which stage of spermatogenesis did this error most likely occur? ---- <<Choices:>> A) Primary spermatocyte B) Secondary spermatocyte C) Spermatid D) Spermatozoon ---- <<Answer:>>
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A
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<<Question:>> A 13-year-old boy presents to the emergency department with severe knee, hip, and groin pain. The patient has a past medical history notable only for obesity and asthma. His temperature is 98°F (36.7°C), blood pressure is 124/65 mmHg, pulse is 128/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for an inability of the patient to bear weight on his left leg and limited range of motion of the left hip. Which of the following is the best management for this patient? ---- <<Choices:>> A) Casting and crutches B) Immobilization of the hip in a Pavlik harness C) Supportive therapy and observation D) Surgical pinning of the femoral head ---- <<Answer:>>
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D
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<<Question:>> A 28-year-old man comes to the physician because of diarrhea and crampy abdominal pain for 5 weeks. He has had up to 4 bowel movements per day. Several times he noticed mucoid strings with the stool. He has abdominal bloating. Over the past month, has had a 3.2-kg (7-lb) weight loss. He has not had fever, cough, or bloody stools. He had a painful rash on his lower extremity 3 weeks ago that resolved spontaneously. He works as a pharmacy technician. His temperature is 37.3°C (98.8°F), pulse is 85/min, and blood pressure is 115/77 mm Hg. The abdomen is soft and nontender. His hemoglobin concentration is 11.9 g/dL, MCV is 79 fL, ferritin is 106 ng/dL, and platelet count is 410,000/mm3; serum concentrations of glucose, creatinine, and electrolytes are within the reference range. This patient's condition is most likely associated with which of the following findings? ---- <<Choices:>> A) Increased serum VIP B) Stool leukocytes C) Melanosis coli D) Normal intestinal mucosa ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 51-year-old man is brought to the emergency department because of a 2-day history of fever, abdominal pain, and confusion. His wife states that he has been unable to recall his birthday or her name. He was diagnosed with hepatitis C 3 years ago but refused treatment. He has been treated twice in the past year for acute pancreatitis. There is no family history of serious illness. His only medication is a calcium supplement. He emigrated from India 15 years ago. He appears ill. His temperature is 38.3°C (100.9°F), pulse is 101/min, and blood pressure is 104/68 mm Hg. He is confused and oriented only to person. Examination shows scleral icterus and spider angiomas. There are fine tremors of the hands bilaterally. The abdomen is distended and shifting dullness is present. There is diffuse tenderness to palpation with no guarding. Bowel sounds are absent. Laboratory studies show: Hemoglobin 12.6 g/dL Leukocyte count 13,900/mm3 Platelet count 342,000/mm3 Serum Albumin 2.6 g/dL Total bilirubin 2.56 mg/dL Alkaline phosphatase 54 U/L AST 17 U/L ALT 44 U/L Paracentesis is performed. Ascitic fluid analysis shows an albumin concentration of 0.8 g/dL, glucose concentration of 62 mg/dL, and a leukocyte count of 1900/mm3 with 60% neutrophils. Which of the following is the most likely explanation for these findings?" ---- <<Choices:>> A) Aseptic peritoneal inflammation B) Neoplastic growth C) Bacterial translocation D) Perforated viscus ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> An 18-month-old girl is brought to the emergency department because of a cough that her parents are worried about. She has had a runny nose and a low-grade fever for the past 2 days, with some hoarseness and a rough-sounding cough that started this afternoon. This evening she began making some high-pitched sounds when taking breaths, and she seemed to be having some trouble breathing. She is alert and does not appear to be in acute distress. She has a temperature of 38.0°C (100.4 °F), with a respiratory rate of 50/min and O2 saturation of 97%. There is audible inspiratory stridor that worsens when she starts to cry during the examination. She has an occasional barking cough. Her pharynx is mildly erythematous with normal tonsils and no exudate. A frontal X-ray of the upper chest airways is obtained (shown in the image). Which of the following is the best step in management? ---- <<Choices:>> A) Anterior-posterior and lateral radiographs of the neck B) Racemic epinephrine and intramuscular corticosteroid therapy C) Intravenous antibiotics D) Trial of bronchodilator therapy and oral steroids ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 43-year-old woman presents with complaints of retrosternal burning associated with eating. It has persisted for the past several years but has been getting worse. Her past medical history is unknown and this is her first time seeing a doctor. She states she is otherwise healthy and review of systems is notable for episodic hand pain that is worse in the winter as well as a chronic and severe cough with dyspnea which she attributes to her smoking. Her temperature is 97.7°F (36.5°C), blood pressure is 174/104 mmHg, pulse is 80/min, respirations are 22/min, and oxygen saturation is 92% on room air. Physical exam is notable for a young appearing woman with coarse breath sounds. Laboratory studies and urinalysis are ordered and currently pending. Which of the following is the pathophysiology of this patient's chief complaint? ---- <<Choices:>> A) Decreased lower esophageal tone B) Esophageal fibrosis C) Increased lower esophageal tone D) Spastic cricopharyngeal muscle ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 67-year-old man with chronic kidney disease comes to the physician because of worsening fatigue and shortness of breath on exertion for 6 months. He has a 20-year history of poorly-controlled type 2 diabetes mellitus. Current medications include metformin and insulin. His pulse is 105/min. Examination shows conjunctival pallor and bounding pulses. Laboratory studies show: Hemoglobin 8.6 g/dL Mean corpuscular volume 90 μm3 Reticulocyte count 0.5% Serum Ferritin 325 ng/mL Urea nitrogen 45 mg/dL Creatinine 2.2 mg/dL The patient is prescribed a drug to treat the cause of his current symptoms. The drug's mechanism of action directly involves which of the following signaling pathways?" ---- <<Choices:>> A) PI3K/Akt/mTOR B) MAP kinase C) JAK/STAT D) IP3 ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 41-year-old man presents to the emergency department with a 6-hour history of muscle cramping, decreased appetite, and diarrhea. He says that these symptoms came on rapidly but does not recall anything that may have triggered the episode. He has never experienced these symptoms before. His past medical history is significant for obesity, sleep apnea, and type 2 diabetes that is well controlled on metformin. He also has gastroesophageal reflux disease for which he occasionally takes antacids. On presentation he is found to have fast, shallow breathing and abdominal pain that is poorly localized. Basic labs as well as an arterial blood gas are obtained and the results are shown below: Na+: 139 mEq/L Cl-: 106 mEq/L HCO3-: 11 mEq/L pH: 7.25 pCO2: 22 mmHg Which of the following is the most likely cause of the changes seen in this patient's labs? ---- <<Choices:>> A) Anxiety B) Diarrhea C) Metformin D) Sleep apnea ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A scientist is studying the properties of myosin-actin interactions in a sample of human muscle tissue. She has identified a drug that selectively inhibits phosphate release by the myosin head. If she gives this drug to a sample of human muscle tissue under physiologic conditions, which of the following steps in cross-bridge cycling will most likely be blocked? ---- <<Choices:>> A) Myosin head cocking B) Exposure of myosin-binding sites on actin C) Myosin head binding to actin D) Power stroke ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 16-year-old boy with a seizure disorder and cognitive delay is brought to the physician because of progressively worsening right lower extremity weakness for the past 6 months. He does not make eye contact and sits very close to his mother. Physical examination shows a grade 3/6 holosystolic murmur at the cardiac apex. Neurological examination shows decreased strength in the right lower leg with normal strength in the other extremities. Fundoscopic examination shows several multinodular, calcified lesions in the retina bilaterally. A photograph of his skin findings is shown. This patient's condition is most likely due to a mutation in which of the following? ---- <<Choices:>> A) NF1 gene on chromosome 17 B) NF2 gene on chromosome 22 C) TSC1 gene on chromosome 9 D) VHL gene on chromosome 3 ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 66-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. He endorses diffuse abdominal tenderness. His past medical history is notable for diabetic nephropathy, hypertension, dyslipidemia, depression, and morbid obesity. He also is currently being treated for an outbreak of genital herpes. His temperature is 99.0°F (37.2°C), blood pressure is 184/102 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man in no acute distress. A CT scan of the abdomen with contrast is performed and is unremarkable. The patient is admitted to the observation unit for monitoring of his pain. Notably, the patient's abdominal pain improves after an enema and multiple bowel movements. The patient's evening laboratory values are ordered and return as seen below. Serum: Na+: 141 mEq/L Cl-: 99 mEq/L K+: 4.8 mEq/L HCO3-: 11 mEq/L BUN: 20 mg/dL Glucose: 177 mg/dL Creatinine: 3.1 mg/dL Which of the following is the most likely etiology of this patient's laboratory derangements? ---- <<Choices:>> A) Acyclovir B) Atorvastatin C) Metformin D) Metoprolol ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 56-year-old man comes to the clinic for a check-up. He presents with a 1-year history of worsening shortness of breath and weight loss. He is a former construction worker, and worked in a steel mill when he was in high school. He is an active smoker with a 36-pack-year smoking history. The blood pressure is 130/78 mm Hg, pulse rate is 90/min, respiratory rate is 17/min, and the BMI is 31 kg/m2. The patient is afebrile and the oxygen saturation at rest is 95% on room air. The pulmonary examination reveals a mildly prolonged expiratory phase, and no wheezing or crackles are auscultated. A pulmonary function test is recommended for the patient, and 2 weeks later he returns with a report that shows an FEV1/FVC ratio of 60% and FEV1 of 50% of the predicted value. The lung volumes show a total lung capacity of 110% of predicted value, a residual volume of 115% of predicted value, and a DLCO of 60% of predicted value. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Asbestosis B) Idiopathic pulmonary fibrosis C) Bronchiectasis D) Chronic obstructive pulmonary disease ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 25-year-old zookeeper presents to the office complaining of a dry cough, fever, and chills for the past month. He states that the symptoms come in episodes at the end of the workday and last a few hours. He also mentions that he is fatigued all the time. His job includes taking care of various types of birds. He is otherwise fine and denies recent travel or trauma. Medical history is unremarkable and he does not take any medications. He does not smoke cigarettes or drinks alcohol. Allergies include peanuts, dust, and pollen. Childhood asthma runs in the family. Chest X-ray reveals diffuse haziness in both lower lung fields. A PPD skin test is negative. What is the most appropriate treatment for this patient? ---- <<Choices:>> A) Thoracocentesis B) Inhaled beclomethasone C) Avoid exposure to birds D) Isoniazid for 6 months ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 60-year-old female presents to her gynecologist with vaginal bleeding. She underwent menopause ten years prior. She has a past medical history of hypertension and diabetes mellitus. On physical examination, her uterus is uniformly enlarged. Ultrasound reveals a thickened endometrial stripe and tissue biopsy reveals neoplastic endometrial cells. A workup for metastatic disease is negative and the gynecologist recommends a laparoscopic hysterectomy. During the procedure, the surgeon ligates multiple vessels in order to remove the entire uterus. In the immediate postoperative period, the patient develops left-sided flank pain and oliguria. Serum creatinine is found to be 1.4 mg/dl whereas it was 1.0 mg/dl prior to the operation. Renal ultrasound is normal. Urinalysis is notable for hematuria. Ligation of which of the following vessels most likely contributed to this patient’s condition? ---- <<Choices:>> A) Artery of Sampson B) Ovarian artery C) Superior vesical artery D) Uterine artery ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 40-year-old man presents to the physician with progressive weight loss for the last 3 months. He also says he frequently sweats profusely at night and has a recurring low-grade fever, for which he takes acetaminophen. The patient denies any symptoms like cough, breathlessness, or gastrointestinal symptoms. His temperature is 37.1ºC (98.8ºF), pulse is 76/min, blood pressure is 116/78 mm Hg, and respiratory rate is 13/min. On physical examination, he has generalized pallor. Bilateral cervical lymphadenopathy is present. Examination of his abdomen reveals non-tender hepatosplenomegaly in the right upper quadrant. Laboratory evaluation confirms the diagnosis of Hodgkin’s lymphoma. Which of the following viral infections is most likely to have played a role in the pathogenesis of this patient’s malignancy? ---- <<Choices:>> A) Epstein-Barr virus B) Human T-cell leukemia virus type 1 C) Human herpesvirus-8 D) Human papillomavirus type 16 ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 28-year-old gravida 1 at 32 weeks gestation is evaluated for an abnormal ultrasound that showed fetal microcephaly. Early in the 1st trimester, she had fevers and headaches for 1 week. She also experienced myalgias, arthralgias, and a pruritic maculopapular rash. The symptoms resolved without any medications. A week prior to her symptoms, she had traveled to Brazil where she spent most of the evenings hiking. She did not use any mosquito repellents. There is no personal or family history of chronic or congenital diseases. Medications include iron supplementation and a multivitamin. She received all of the recommended childhood vaccinations. She does not drink alcohol or smoke cigarettes. The IgM and IgG titers for toxoplasmosis were negative. Which of the following is the most likely etiologic agent? ---- <<Choices:>> A) Dengue virus B) Rubella virus C) Toxoplasmosis D) Zika virus ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 41-year-old G3P1 woman presents with a sudden onset throbbing headache, tinnitus, nausea, and left-sided weakness. Patient has no significant past medical history and takes no medications. Her last two pregnancies ended with spontaneous abortions before the 10th week of gestation. No significant family history. Her vital signs include: blood pressure 130/90 mm Hg, pulse 58/min, respiratory rate 11/min, and temperature 36.8℃ (98.2℉). GCS is 14/15. Physical examination shows 3+ deep tendon reflexes and increased muscle tone in the left upper and lower extremities. Laboratory findings are significant for the following: Platelet count 230,000/mm3 Fibrinogen 3.5 g/L Activated partial thromboplastin time 70 s Thrombin time 34 s A non-contrast CT of the head is performed and shown in the picture. Which of the following would be the next best diagnostic step in this patient? ---- <<Choices:>> A) Mixing study B) INR C) Ristocetin-induced platelet aggregation test D) Clot retraction study ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A obstetrician is working in a developing country to help promote maternal health and fetal well being. While there, he delivers a baby who he suspects has congenital hypothyroidism, most likely caused by inadequate maternal iodine intake. Which of the following signs and symptoms would NOT be expected to be observed in this child? ---- <<Choices:>> A) Hypotonia B) Diarrhea C) Umbilical hernia D) Macroglossia ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 33-year-old nurse is referred to an infectious disease specialist after she exhibited a PPD skin test with 17 mm of induration. She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months. Her temperature is 97.0°F (36.1°C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. An initial chest radiograph is unremarkable. Which of the following is the most appropriate management of this patient? ---- <<Choices:>> A) Isoniazid B) No management indicated C) Repeat PPD in 1 week D) Rifampin, isoniazid, pyrazinamide, and ethambutol ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> An 81-year-old woman is brought to the emergency room by her son after witnessing the patient fall and hit her head. The son reports that the patient was in her usual state of health until she complained of chest palpitations. This startled her while she was climbing down the stairs and lead to a fall. Past medical history is significant for hypertension and atrial fibrillation. Medications are lisinopril, metoprolol, and warfarin. Temperature is 99°F (37.2°C), blood pressure is 152/96 mmHg, pulse is 60/min, respirations are 12/min, and pulse oximetry is 98% on room air. On physical examination, she is disoriented and at times difficult to arouse, the left pupil is 6 mm and non-reactive to light, and the right pupil is 2 mm and reactive to light. A right-sided visual field defect is appreciated on visual field testing. There is 1/5 strength on the right upper and lower extremity; as well as 5/5 strength in the left upper and lower extremity. A computerized tomography (CT) scan of the head is shown. Which of the following most likely explains this patient’s symptoms? ---- <<Choices:>> A) Herniation of the uncus B) Herniation of the cingulate gyrus C) Occlusion of the basilar artery D) Occlusion of the anterior spinal artery ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 67-year-old man with peripheral neuropathy comes to the physician for a follow-up examination after the results of serum protein electrophoresis showed monoclonal gammopathy. A complete blood count, serum creatinine, and serum electrolyte concentrations are within the reference ranges. A bone marrow biopsy shows 6% monoclonal plasma cells. Further analysis shows that class I major histocompatibility molecules are downregulated in these monoclonal plasma cells. The proliferation of these monoclonal plasma cells is normally prevented by a class of immune cells that lyse abnormal cells without the need for opsonization, priming, or prior activation. Which of the following best describes this class of immune cells? ---- <<Choices:>> A) Bone marrow-derived macrophages B) CD4+ T lymphocytes C) Natural killer cells D) Band neutrophils ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 47-year-old woman comes to the physician because of progressive muscle weakness for five months. She feels that the muscles in her shoulders and hips have been getting weaker and sometimes feel sore. She now has difficulty getting up from chairs, climbing stairs, and combing her hair. She has also noticed new difficulty with swallowing solid foods, but has no trouble with liquids. She has a 5-year history of hyperlipidemia controlled with fluvastatin. Her maternal uncle died at age 26 from Duchenne's muscular dystrophy and her mother has Hashimoto's thyroiditis. Vital signs are within normal limits. Neurologic examination shows moderate weakness in the arm abductors and hip flexors bilaterally. Deep tendon reflexes are 2+ bilaterally. Laboratory studies show: Hemoglobin 13.7 g/dL Leukocytes 11,200/mm3 Erythrocyte sedimentation rate 33 mm/h Serum Creatine kinase 212 U/L Lactate dehydrogenase 164 U/L AST 34 U/L ALT 35 U/L Which of the following is most likely to confirm the diagnosis?" ---- <<Choices:>> A) Intrafascicular infiltration on muscle biopsy B) Perifascicular and perivascular infiltration on muscle biopsy C) Positive anti-acetylcholine receptor antibodies D) Dystrophin gene mutation on genetic analysis ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 41-year-old man presents to the emergency room with sudden onset of blurry vision one hour ago. He states that he was resting at home when he noticed he had difficulty reading. Currently, he is also starting to see double, and is seeing two images on top of each other. Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before. When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor. He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier. While in the emergency room, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min. Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes. The remainder of his exam is normal. Which of the following is the pathogenesis of this patient’s presentation? ---- <<Choices:>> A) Decreased acetylcholine release B) Overactivation of adenylate cyclase C) Release of interferon-gamma D) Inhibition of GABA release ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 4-week-old female newborn is brought to the physician because of increasing yellowing of her eyes and skin for 2 weeks. The mother has noticed that the girl's stools have become pale over the past week. She was breastfed since birth but her parents switched her to formula feeds recently after reading on the internet that breastfeeding could be the cause of her current symptoms. The patient was delivered vaginally at 38 weeks' gestation. Pregnancy and delivery were uncomplicated. She appears healthy. Vital signs are within normal limits. She is at the 50th percentile for length and at the 60th percentile for weight. Examination shows scleral icterus and jaundice. The liver is palpated 2 cm below the right costal margin. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Serum studies show: Bilirubin Total 15 mg/dL Direct 12.3 mg/dL Alkaline phosphatase 2007 U/L AST 53 U/L ALT 45 U/L γ-glutamyl transferase 154 U/L Blood group A positive Which of the following is the most likely diagnosis?" ---- <<Choices:>> A) Galactosemia B) Biliary atresia C) Crigler–Najjar syndrome D) Breast milk jaundice ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 43-year-old man comes to the emergency department with nausea, abdominal discomfort, diarrhea, and progressive perioral numbness for the past 24 hours. 3 days ago, he underwent a total thyroidectomy for treatment of papillary thyroid cancer. His only medication is a multivitamin supplement. He appears fatigued. While measuring the patient's blood pressure, the nurse observes a spasm in the patient's hand. Physical examination shows a well-healing surgical wound on the neck. Which of the following ECG findings are most likely in this patient? ---- <<Choices:>> A) Torsade de pointes B) QT prolongation C) Peaked T waves D) PR prolongation ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 68-year-old woman presents with left lower quadrant pain that worsens with defecation. She describes the pain as 'crampy'. She also says she has suffered from mild constipation for the past few years. The patient denies any recent weight change or urinary symptoms. Her last menstrual period was 16 years ago. Her body temperature is 37.8°C (100.0°F), pulse is 102/min, respiratory rate is 16/min, and blood pressure is 133/87 mm Hg. On physical examination, tenderness to palpation in the left lower quadrant is present. The laboratory studies are presented as follows: Hemoglobin 13.2 mg/dL Hematocrit 48% Leukocyte count 16,000/mm³ Neutrophils 89% Bands 5% Eosinophils 0% Basophils 0% Lymphocytes 11% Monocytes 0% Platelet count 380,000/mm³ Which of the following is the most likely diagnosis in this patient? ---- <<Choices:>> A) Diverticulitis B) Hypothyroidism C) Adenocarcinoma of the colon D) Irritable bowel syndrome ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 67-year-old man presents to his primary care physician for erectile dysfunction. He states that for the past month he has been unable to engage in sexual intercourse with his wife despite having appropriate sexual desire. He also endorses deep and burning buttock and hip pain when walking, which is relieved by rest. The patient states that he does not have erections at night or in the morning. His past medical history is notable for diabetes, coronary artery disease, and hypertension, and he has a 40 pack-year smoking history. Physical exam is notable for weak lower extremity and femoral pulses. Which of the following is the most specific etiology of this patient’s symptoms? ---- <<Choices:>> A) Anxiety B) Aortoiliac atherosclerosis C) Spinal stenosis D) Vascular claudication ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 55-year-old man with a history of chronic glomerulonephritis due to IgA nephropathy presents to your office with bone pain. Which of the following laboratory findings would you most expect upon analysis of this patient's serum? ---- <<Choices:>> A) Increased PTH, decreased calcium, increased phosphate, decreased calcitriol B) Decreased PTH, increased calcium, increased phosphate, increased calcitriol C) Decreased PTH, decreased calcium, increased phosphate, decreased calcitriol D) Normal PTH, normal calcium, normal phosphate, normal calcitriol ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A medical researcher is studying the physiology of the immune system in order to better understand the effects of HIV on patients. He isolates a group of cells that are shown by flow cytometry to be positive for the cell surface marker CD8. He then mixes this cell population with a group of infected cells, crosslinks extracellular interactions, and immunoprecipitates the CD8 protein. He identifies a protein bound to CD8 that is composed of two chains from an adjacent cell. Which of the following best describes the primary function of the protein that was most likely identified? ---- <<Choices:>> A) Binds complement proteins on the cell surface B) Binds endogenous peptides that are present in the endosome C) Binds endogenous peptides that have been transported by the TAP channel D) Binds exogenous peptides that are present in the endosome ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 61-year-old Caucasian male presents to your office with chest pain. He states that he is worried about his heart, as his father died at age 62 from a heart attack. He reports that his chest pain worsens with large meals and spicy foods and improves with calcium carbonate. He denies dyspnea on exertion and an ECG is normal. What is the most likely cause of this patient's pain? ---- <<Choices:>> A) Partially occluded coronary artery B) Umbilical hernia C) Gastroesophageal junction incompetence D) Intestinal metaplasia at the gastroesophageal junction ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 36-year-old woman comes to the clinic because of tearing and a foreign body sensation in her eyes bilaterally, which has gradually worsened over the last several weeks. She also notes having occasional palpitations, nervousness, sweating, and heat intolerance. Her past medical history is unremarkable. She reports a 20-pack-year smoking history and is currently a daily smoker. Physical examination shows an anxious, trembling woman. She has eyelid retraction bilaterally, with an inability to fully close her eyes. Her extraocular motility is limited on upgaze. There is no thyromegaly, and no thyroid nodules are noted. Laboratory studies reveal a thyroid-stimulating hormone level of 0.1 μU/mL and total T4 of 42 μg/dL. Thyroid-stimulating immunoglobulin is positive. CT scan of the orbits shows proptosis and marked enlargement of the extraocular muscle with sparing of the tendons. Which of the following would most likely transiently worsen this patient’s eye symptoms? ---- <<Choices:>> A) External orbital radiation B) Selenium supplementation C) Systemic corticosteroids D) Treatment with radioactive iodine ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 7-year-old boy is brought to a pediatrician by his parents for evaluation of frequent bed wetting during the night. A detailed history reveals that there has been no history of urinary incontinence during the day since the boy was 4 years of age, but that he has never been dry at night continuously for 1 week. There is no history of urinary tract infections, urgency, frequency, or hesitancy. On physical examination, the boy’s vital signs are stable. His neurologic and abdominal examinations are completely normal. His laboratory investigations are as follows: Urine-specific gravity (first-morning sample) 1.035 Urine red blood cells Absent Urine pus cells Absent Urine culture Negative Which of the following is the next step in the management of this patient? ---- <<Choices:>> A) Magnetic resonance imaging (MRI) of the spine B) Reassuring the parents and use of an enuresis alarm C) Treatment with oral oxybutynin D) Treatment with oral imipramine ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 52-year-old man with a history of gastric cancer that was treated with subtotal gastrectomy dies in a motor vehicle collision. At autopsy, examination of the spinal cord shows unilateral atrophy of the neurons in the area indicated by the arrow. Neurological examination of the patient when he was still alive would most likely have shown which of the following findings? ---- <<Choices:>> A) Decreased sense of temperature in the ipsilateral arm B) Decreased strength of the contralateral leg C) Decreased vibratory sense in the ipsilateral arm D) Decreased positional sense in the ipsilateral leg ---- <<Answer:>>
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D
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 24-year-old pregnant woman at 28 weeks gestation presents to the emergency department with complaints of fever with chills and pain in her knee and ankle joints for the past 2 days. She also complains of headaches and difficulty moving her neck. Further questioning reveals that she had a tick bite on her arm while gardening a few days ago. Past medical history is noncontributory. She takes a multivitamin with iron and folate every day and has been receiving regular prenatal care and the pregnancy is progressing normally. On examination, an erythematous rash is seen on her right arm, as shown in the accompanying photograph. Her obstetric examination is normal. Ultrasound of the fetus is reassuring with a normal heartbeat and no gross abnormalities. A specimen is collected to test for Lyme disease. What is the next best step for this patient? ---- <<Choices:>> A) Ibuprofen B) Tetracycline C) Amoxicilin D) Gentamicin ---- <<Answer:>>
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C
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 25-year-old woman presents to her physician with a four month history of fatigue and weakness. The weakness has been progressive to the point where she cannot climb stairs and stand from a sitting position. She has only had one menstrual period in the last four months and has never been pregnant. She smokes a pack of cigarettes every day and does not take any medications. Her temperature is 98°F (36.7°C), blood pressure is 160/100 mmHg, pulse is 70/min, and respirations are 15/min. She is obese with a significant pannus. Abdominal striae are present. Her laboratory workup is notable for the following: Serum: Na+: 142 mEq/L Cl-: 102 mEq/L K+: 3.9 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 314 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.1 mg/dL AST: 9 U/L ALT: 8 U/L 24-hour urinary cortisol: 470 µg (< 300 µg) Serum cortisol 30 µg/mL (5-23 µg/dL) Serum adrenocorticotropin-releasing hormone (ACTH) 2 pg/mL (> 5 pg/mL) A 48-hour high dose dexamethasone suppression trial shows that her serum cortisol levels do not decrease. What is the best next step in management? ---- <<Choices:>> A) MRI of the adrenal glands B) MRI of the chest C) Low dose dexamethasone suppression test D) Inferior petrosal sinus sampling ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 67-year-woman with non-Hodgkin lymphoma comes to the physician because of progressively increasing numbness and tingling in her fingers and toes. Her last cycle of chemotherapy with vincristine was 1 week ago. Physical examination shows decreased sensation to light touch in all distal extremities. Knee and ankle deep tendon reflexes are decreased. Which of the following is the most likely underlying mechanism of this patient’s peripheral neuropathy? ---- <<Choices:>> A) Inhibition of beta-tubulin polymerization B) Creation of free radicals that unwind DNA C) Inhibition of dihydrofolate reductase D) Incorporation of false pyrimidine analogues into DNA ---- <<Answer:>>
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A
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 68-year-old man comes to the physician with a 1-week history of painless hematuria. A CT scan of the urinary tract shows areas of bladder wall thickening. Cystoscopy shows several sessile masses with central necrosis arising from the bladder wall. A biopsy specimen of the bladder masses shows moderately differentiated urothelial cells with abundant mitotic figures and nuclear atypia. The patient most likely has a history of exposure to which of the following? ---- <<Choices:>> A) Ionizing radiation B) Aromatic amines C) Aflatoxins D) Radon ---- <<Answer:>>
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B
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Answer the following medical question with the correct letter choice:
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<<Question:>> A 14-year-old girl comes to the physician with her father for evaluation of her short stature. She feels well overall, but is concerned because all of her friends are taller than her. Her birth weight was normal. Her father reports he had a short stature during his teenage years; he is currently 177 cm (5 ft 10 in) tall. She is at the 2ndpercentile for height and 35th percentile for weight. Breast development is Tanner stage 2. Pubic and axillary hair is absent. An x-ray of the left hand and wrist shows a bone age of 11 years. Which of the following is the most appropriate next best step in management? ---- <<Choices:>> A) Pelvic ultrasound B) Measure serum dehydroepiandrosterone levels C) Reassurance and follow-up D) MRI of the brain ---- <<Answer:>>
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C
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