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Answer the following medical question with the correct letter choice:
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<<Question:>> Three days after undergoing a laparoscopic Whipple's procedure, a 43-year-old woman has swelling of her right leg. She does not have pain. She has nausea but has not vomited. She was diagnosed with pancreatic cancer 1 month ago. She has been using an incentive spirometer every 6 hours since recovering from her surgery. Prior to admission, her only medications were a multivitamin and an herbal weight-loss preparation. She appears uncomfortable. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 118/78 mm Hg. Examination shows mild swelling of the right thigh to the ankle; there is no erythema or pitting edema. Homan's sign is negative. The abdomen is soft and shows diffuse tenderness to palpation. There are five abdominal laparoscopic incisions with no erythema or discharge. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) CT pulmonary angiography B) Compression ultrasonography C) D-dimer level D) 2 sets of blood cultures " ---- <<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 36-year-old man presents to a physician after having a transient loss of consciousness while resting after dinner the previous night. His symptoms only lasted for a few seconds and resolved spontaneously. This is the third time he experienced such an episode. He says that he recently started having nightmares. His father died of sudden cardiac death at the age of 45 years without a history of hypertension or any chronic cardiac disorder. A complete physical examination was normal. A 12-lead electrocardiogram showed ST-segment elevations in V1, V2, and V3, and the presence of incomplete right bundle branch block (RBBB). After a complete diagnostic evaluation, Brugada syndrome was diagnosed. He has prescribed a class I anti-arrhythmic drug, which is a sodium channel blocker that slows phase 0 depolarization in ventricular muscle fibers. The drug also blocks potassium channels and prolongs action potential duration, but it does not shorten phase 3 repolarization. The drug also has mild anticholinergic and alpha-blocking activity. If taken in high doses, which of the following are the most likely side effects of the drug? ---- <<Choices:>> A) Headache and tinnitus B) Pulmonary fibrosis and corneal deposits C) Pedal edema and flushing D) Hypothyroidism and phototoxicity ---- <<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 52-year-old man is brought to the emergency department for recurrent vomiting that began 5 hours ago. He describes the vomitus as bloody and containing black specks. He drinks 10–12 beers daily and has not seen a physician in 15 years. He appears pale. His temperature is 36.7°C (98.1°F), pulse is 122/min, and blood pressure is 85/59 mm Hg. Physical examination shows decreased radial pulses, delayed capillary refill, multiple spider angiomata, and a distended abdomen. He is oriented to person but not to place or time. Which of the following is most likely decreased in this patient in response to his current condition compared to a healthy adult? ---- <<Choices:>> A) Systemic vascular resistance B) Fractional tissue oxygen extraction C) Carotid baroreceptor firing activity D) Cardiac inotropy ---- <<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 69-year-old male with a longstanding history of hypertension and high cholesterol presents with abdominal pain and ‘bruising on his feet’. The patient states that his symptoms started about a week ago and have steadily worsened. He describes the abdominal pain as mild to moderate, dull, and deeply localized to the umbilical region. Past medical history is significant for 2 transient ischemic attacks 6 months prior, characterized by a sudden right-sided weakness and trouble speaking but recovered fully within 30 minutes. Current medications are sildenafil 100 mg orally as needed. Patient reports a 30-pack-year smoking history and heavy alcohol use on the weekends. Review of systems is significant for decreased appetite and feeling easily full. Vitals are temperature 37°C (98.6°F), blood pressure 155/89 mm Hg, pulse 89/min, respirations 16/min, and oxygen saturation 98% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is normal. Lungs are clear to auscultation. Carotid bruit present on the right. The abdomen is soft and nontender. Bowel sounds present. A pulsatile abdominal mass is felt in the lower umbilical region. Patient’s feet have the following appearance seen in the picture. Abdominal ultrasound reveals the presence of an abdominal aortic aneurysm (AAA). Contrast CT reveals a small, unruptured AAA (diameter 4.1 cm). High flow supplemental oxygen and fluid resuscitation are initiated. Morphine sulfate and metoprolol are administered. Which of the following is the best course of treatment for this patient? ---- <<Choices:>> A) Discharge with clinical surveillance and ultrasound every 6 months B) Elective endovascular repair C) Elective open surgical repair D) Emergency open surgical repair ---- <<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 38-year-old woman undergoes a partial thyroidectomy for an enlarged thyroid gland compressing the trachea. During surgery, a young surgeon ligates the inferior thyroid arteries as close to the poles as possible to prevent intraoperative hemorrhage. 2 weeks later, the patient presents to the outpatient clinic with hoarseness. What could be the most likely cause of her hoarseness? ---- <<Choices:>> A) Internal laryngeal nerve injury B) Recurrent laryngeal nerve injury C) External laryngeal nerve injury D) Laryngeal edema ---- <<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 17-year-old man presents to his family physician for an evaluation about the size of his penis. He feels increasingly anxious during physical education (PE) class as he has noticed that the size of his penis is significantly smaller when compared to his peers. Based on the physical examination, he is Tanner stage 1. The weight and height are 60 kg (132 lb) and 175 cm (5 ft 9 in), respectively. The cardiopulmonary examination is normal; however, the patient has difficulty identifying coffee grounds by smell. Which of the following explains the pathophysiology underlying this patient’s disorder? ---- <<Choices:>> A) Expansion of a CTG trinucleotide repeat B) Isolated gonadotropin-releasing hormone (GnRH) deficiency C) Sex-specific epigenetic imprinting D) Non-disjunction of sex chromosomes ---- <<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 63-year-old man is aiming to improve his health by eating a well balanced diet, walking daily, and quitting smoking following a 45-year smoking history. While on his daily walks he notices a strong cramping pain in his calves that consistently appears after a mile of walking. He sees his physician and a diagnosis of peripheral artery disease with intermittent claudication is made. To improve his symptoms, cilostazol is prescribed. What is the mechanism of action of this medication? ---- <<Choices:>> A) Irreversible cyclooxygenase inhibitor B) Thromboxane synthase inhibitor C) Adenosine diphosphate receptor inhibitor D) Phosphodiesterase inhibitor ---- <<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 37-year-old man comes to the emergency department with the chief complaint of a high fever for several days. In addition to the fever, he has had malaise, chest pain, and a dry cough. He recently went on vacation to South America but has returned to his job delivering packages. He has several friends who recently had influenza. Hi temperature is 102.8°F (39.3 °C), blood pressure is 137/80 mmHg, pulse is 104/min, respirations are 19/min, and oxygen saturation is 98%. Chest exam reveals a deep noise found bilaterally in the lung bases. Chest radiograph reveals a wider area of opacity near the heart and bilateral lung infiltrates. Which of the following is characteristic of the most likely organism responsible for this patient's symptoms? ---- <<Choices:>> A) Cultured on charcoal and yeast B) D-glutamate capsule C) Found in desert sand D) Polyribosyl-ribitol-phosphate capsule ---- <<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 34-year-old man presents to the emergency department complaining of headache, fever, chills, cough, shortness of breath, and chest pain for the past 4 days. He smokes 2 packs per day and drinks 2–3 beers every day. He denies any previous medical problems except for seasonal allergies for which he takes diphenhydramine on occasions. At the hospital, the vital signs include: temperature 40.0°C (104.0°F), blood pressure 140/80 mm Hg, heart rate 98/min, and respiratory rate 28/min. On physical exam, he is thin and poorly kept. His clothes appear dirty. Small scars are visible in the decubitus region of both arms. The lung sounds are equal with bilateral crackles, and heart auscultation reveals a systolic murmur that radiates to the left axilla. Petechiae are seen on the hard palate and palms of his hands. A chest X-ray and blood cultures are ordered. What is the most likely organism causing his symptoms? ---- <<Choices:>> A) Streptococci viridans B) Staphylococcus aureus C) Aspergillus fumigatus D) Staphylococcus epidermidis ---- <<Answer:>>
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B
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<<Question:>> A 42-year-old man presents to a neurologist for evaluation of severe headache. He started experiencing episodic headaches and palpitations 3 months ago; however, he thought that these symptoms were simply related to the stress of moving and starting a new job. He has continued to experience these intermittent headaches and has also noticed that he sweats profusely during these episodes. On presentation his temperature is 99.1°F (37.3°C), blood pressure is 163/112 mmHg, pulse is 112/min, and respirations are 15/min. Physical exam reveals pallor and perspiration but is otherwise unremarkable. The most likely cause of this patient's symptoms is produced by cells located in which region of the histology slide shown in figure A? ---- <<Choices:>> A) A B) B C) C D) E ---- <<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 62-year-old woman presents to the emergency department for vision changes. About 90 minutes ago she was on the couch watching television with her husband when she suddenly noticed that she couldn't see the screen normally. She also felt a little dizzy. She has never had anything like this happen before. Her general physical exam is unremarkable. Her neurologic exam is notable for loss of vision in the right visual field of both eyes with macular sparing, though extraocular movements are intact. A computed tomography (CT) scan of the head shows no acute intracranial process. Angiography of the brain will most likely show a lesion in which of the following vessels? ---- <<Choices:>> A) Internal carotid artery B) Anterior cerebral artery C) Posterior cerebral artery D) Basilar artery ---- <<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 three-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow. She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding the infant but feels the latch has been poor and is unsure how much milk he has been consuming but feels it is not enough. A lactation consult was called for the patient and it was noted that despite proper instruction the observed latch was still poor. When asked the mother stated that the baby is currently making stools 2 times per day. Which of the following is the most likely etiology of the patient's presentation? ---- <<Choices:>> A) Breast milk jaundice B) Breastfeeding jaundice C) Sepsis D) Physiologic hyperbilirubinemia ---- <<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 59-year-old man is brought to the emergency department with a history of black, tarry stools but denies vomiting of blood or abdominal pain. His family has noticed progressive confusion. History is significant for liver cirrhosis and alcoholism. His heart rate is 112/min, temperature is 37.1°C (98.7°F), and blood pressure is 110/70 mm Hg. On examination, he is jaundiced, lethargic, is oriented to person and place but not date, and has moderate ascites. Neurological examination reveals asterixis, and his stool is guaiac-positive. Liver function test are shown below: Total albumin 2 g/dL Prothrombin time 9 seconds Total bilirubin 5 mg/dL Alanine aminotransferase (ALT) 100 U/L Aspartate aminotransferase (AST) 220 U/L Which of the following is a feature of this patient condition? ---- <<Choices:>> A) Ammonia level is the best initial test to confirm the diagnosis B) It is a diagnosis of exclusion C) It only occurs in patients with cirrhosis D) Electroencephalography (EEG) usually shows focal localising abnormality ---- <<Answer:>>
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B
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<<Question:>> A 20-year-old healthy man is running on a treadmill for the last 30 minutes. He is in good shape and exercises 3 times per week. He takes no medications and denies smoking cigarettes, drinking alcohol, and illicit drug use. Prior to starting his run, his heart rate was 70/min, and the blood pressure was 114/74 mm Hg. Immediately after stopping his run, the heart rate is 130/min, and the blood pressure is 145/75 mm Hg. Which of the following is most likely responsible for the change in his heart rate and blood pressure? ---- <<Choices:>> A) Baroreceptor reflex B) Increased activation of the vagal nuclei C) Sympathetic nervous system activation D) Vasopressin release from the pituitary ---- <<Answer:>>
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C
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<<Question:>> A 14-year-old obese boy presents with severe right hip and knee pain. The patient says that he has been limping with mild pain for the past three weeks, but the pain acutely worsened today. He describes the pain as severe, non-radiating, sharp and aching in character, and localized to the right hip and knee joints. The patient denies recent illness, travel, trauma, or similar symptoms in the past. No significant past medical history and no current medications. The patient is not sexually active and denies any alcohol, smoking or drug use. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 99% on room air. Body mass index (BMI) is 32 kg/m2. On physical examination, the patient is alert and cooperative. The right leg is externally rotated, and there is a limited range of motion in the right hip. Strength is 4 out of 5 at the right hip joint and 5 out of 5 elsewhere. There is no tenderness to palpation. No joint erythema, edema or effusion present. Sensation is intact. Deep tendon reflexes are 2+ bilaterally. Laboratory tests are unremarkable. Plain radiographs of the right hip joint are significant for displacement of the right femoral head inferoposterior off the femoral neck. Which of the following is the most appropriate course of treatment for this patient? ---- <<Choices:>> A) Reassess in 3 months B) Intra-articular corticosteroid injection of the right hip joint C) Pavlik harness D) Surgical pinning of the right hip ---- <<Answer:>>
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D
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<<Question:>> A 32-year-old man comes to the physician because of a progressive development of tender breast tissue over the past 18 months. He used to ride his bicycle for exercise 4 times a week but stopped after he had an accident and injured his left testicle 3 months ago. He has gained 5 kg (11 lb) during this period. For the last 10 years, he drinks one to two beers daily and sometimes more on weekends. He occasionally takes pantoprazole for heartburn. He is 171 cm (5 ft 7 in) tall and weighs 87 kg (192 lb); BMI is 30 kg/m2. Vital signs are within normal limits. Examination shows bilaterally symmetrical, mildly tender gynecomastia. A nontender 1.5-cm mass is palpated in the left testis; transillumination test is negative. The remainder of the examination shows no abnormalities. Which of the following is the most likely underlying cause of these findings? ---- <<Choices:>> A) Leydig cell tumor B) Obesity C) Klinefelter syndrome D) Trauma to testis ---- <<Answer:>>
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A
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<<Question:>> A 58-year-old man comes to the physician because he is unable to achieve erections during sexual intercourse. He first noticed the problem 8 months ago, when he became sexually active with a new girlfriend. He states that his relationship with his girlfriend is good, but his inability to engage in sexual intercourse has been frustrating. He has hyperlipidemia and was diagnosed with major depressive disorder 3 years ago. He works as a lawyer and enjoys his job, but he has had a great deal of stress lately. He had not been sexually active for the previous 3 years, since the death of his wife. He does not smoke. He drinks 4–6 beers on weekends. Current medications include simvastatin and citalopram. His temperature is 37.5°C (99.5°F), pulse is 80/min, and blood pressure is 135/82 mm Hg. BMI is 30 kg/m2. Pedal pulses are difficult to palpate. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Psychotherapy B) Penile prosthesis insertion C) Nocturnal penile tumescence testing D) Switch citalopram to bupropion ---- <<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 male presents to the pediatrician with a 10-day history of cough that is worse at night. The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief. He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea. The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies. In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min. The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses. His pharynx is erythematous with symmetric swelling of the tonsils. On lung exam, he has moderate bilateral expiratory wheezing. Which of the following is the best next step in management? ---- <<Choices:>> A) Amoxicillin B) Amoxicillin-clavulanic acid C) Clindamycin D) Levofloxacin ---- <<Answer:>>
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B
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<<Question:>> A 65-year-old man, known to have chronic obstructive lung disease for the last 3 years, presents to the emergency department with a cough, breathing difficulty, and increased expectoration for a day. There is no history of fever. His regular medications include inhaled salmeterol and inhaled fluticasone propionate. He was a chronic smoker but quit smoking 2 years ago. His temperature is 37.1°C (98.8°F), the pulse rate is 88/min, the blood pressure is 128/86 mm Hg, and the respirations are 30/min. On physical examination, the use of the accessory muscles of respiration is evident and the arterial saturation of oxygen is 87%. Auscultation of the chest reveals the presence of bilateral rhonchi with diminished breath sounds in both lungs. Which of the following medications, if administered for the next 2 weeks, is most likely to reduce the risk of subsequent exacerbations over the next 6 months? ---- <<Choices:>> A) Oral prednisone B) Supplemental oxygen C) Montelukast D) Nebulized N-acetylcysteine ---- <<Answer:>>
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A
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<<Question:>> A 22-year-old woman presents to the emergency department for abdominal pain. The patient has been trying to get pregnant and was successful recently, but now she is experiencing abdominal pain, contractions, and a bloody vaginal discharge. According to her last appointment with her primary care provider, she is 10 weeks pregnant. The patient has a past medical history of constipation, anxiety, and substance abuse. She is not currently taking any medications. Her temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a bloody vaginal discharge and an open cervix. The patient is initially extremely grateful for the care she is receiving and thanks the doctor and the nursing staff for saving her baby. Upon hearing the news that she is having a spontaneous abortion, the patient becomes angry and aggressive and states that her physician and the medical staff are incompetent, evil, and she is going to sue all of them. The patient is left to grieve but upon entering the room again you notice that the patient has new lacerations over her wrists and that some of the medical equipment in the room is broken. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Antisocial personality disorder B) Borderline personality disorder C) Normal grief response D) Post-traumatic stress disorder ---- <<Answer:>>
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B
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<<Question:>> A 45-year-old female presents to the emergency department with gross hematuria and acute, colicky flank pain. She denies any previous episodes of hematuria. She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain. The patient’s blood pressure and temperature are normal, but she is found to have proteinuria. Physical examination is negative for palpable flank masses. Which of the following is the most likely diagnosis: ---- <<Choices:>> A) Diffuse cortical necrosis B) Chronic pyelonephritis C) Papillary necrosis D) Acute Nephrolithiasis ---- <<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 40-year-old man presents to the clinic with complaints of increased bilateral pain in his knees. The pain developed over time and now limits his mobility. He states that the pain is worse at the end of the day, though he does have some early-morning stiffness lasting about 20 minutes. He used to have some success with over-the-counter NSAIDs; however, they no longer help. The patient also has been taking metformin for the past 2 years and is severely obese, with a BMI of 41 kg/m2. Additionally, he states that he has felt increasingly tired during the day, often dozes off during work, and no longer feels refreshed when he wakes up in the morning. Upon examination, there is no tenderness on palpation or erythema; however, some crepitus is felt. He has no other complaints but has a family history of rheumatoid arthritis (RA) on his mother’s side. Which of the following factors is the underlying cause of the patient’s pain, as well as the rest of his complaints? ---- <<Choices:>> A) Medication side effect B) Excess weight C) Infection D) Occult malignancy ---- <<Answer:>>
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B
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<<Question:>> A 40-year-old man comes to the physician because of shortness of breath, double vision, and fatigue for the past 4 weeks. He has no history of serious medical illness and takes no medications. Physical examination shows drooping of the eyelids bilaterally. He is unable to hold his arms up for longer than 3 minutes. A CT scan of the chest shows an anterior mediastinal mass with smooth contours. A photomicrograph of a specimen from the mass is shown. Which of the following immunologic processes normally occurs in the region indicated by the arrow? ---- <<Choices:>> A) B-cell maturation B) V(D)J recombination C) Thymocyte formation D) Negative selection ---- <<Answer:>>
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D
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<<Question:>> A 24-year-old man is brought in to the emergency department by his parents who found him in his room barely responsive and with slurring speech. The patients’ parents say that a bottle of oxycodone was found at his bedside and was missing 15 pills. On physical examination, the patient appears drowsy and lethargic and is minimally responsive to stimuli. His respiratory rate is 8/min and shallow, blood pressure is 130/90 mm Hg, and pulse is 60/min. On physical examination, miosis is present, and the pupils appear pinpoint. The patient is given a drug to improve his symptoms. Which of the following is the mechanism of action of the drug that was most likely administered? ---- <<Choices:>> A) μ, κ, and ẟ receptor antagonist B) μ receptor agonist C) к receptor agonist and μ receptor antagonist D) μ receptor partial agonist and к receptor agonist ---- <<Answer:>>
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A
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<<Question:>> A 27-year-old woman comes to the physician because of increasing shortness of breath and a non-productive cough for 2 months. She has been unable to perform her daily activities. She has had malaise and bilateral ankle pain during this period. She noticed her symptoms after returning from a vacation to Arizona. She is a research assistant at the university geology laboratory. She is originally from Nigeria and visits her family there twice a year; her last trip was 3 months ago. Her temperature is 37.8°C (100°F), pulse is 100/min, respirations are 24/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. There is no palpable cervical or axillary lymphadenopathy. The lungs are clear to auscultation. Her left eye is notable for ciliary injection and photophobia. The remainder of the examination shows no abnormalities. A complete blood count is within the reference range. An x-ray of the chest is shown. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Sarcoidosis B) Pulmonary tuberculosis C) Hodgkin's lymphoma D) Histoplasmosis ---- <<Answer:>>
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A
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<<Question:>> A 75-year-old man presents to his physician with a 1-year history of dysphagia for solids. His more recent complaints include dysphagia for liquids as well. The patient states that he has no difficulty initiating swallowing but occasionally food is stuck in his throat. He does not complain of pain while swallowing but has noticed minor unintentional weight loss. The patient has no history of speech-related pain or nasal regurgitation. His family history is unremarkable. During the examination, the patient appears ill, malnourished, and slightly pale. He is not jaundiced nor cyanotic. Physical examination is unremarkable. A swallowing study reveals a small outpouching in the posterior neck (see image). Which nerve is most likely involved in this patient’s symptoms? ---- <<Choices:>> A) CN X B) CN VII C) CN IX D) CN V ---- <<Answer:>>
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A
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<<Question:>> A 48-year-old female presents with an enlargement of her anterior neck which made swallowing very difficult for 2 weeks now. She has had constipation for the past 6 weeks and overall fatigue. She also had heavy menstrual bleeding; and often feels extremely cold at home. On the other hand, she has well-controlled asthma and spring allergies. On examination, the thyroid is stony hard, tender and asymmetrically enlarged. There is also pain associated with swallowing. Laboratory studies show a serum T4 level of 4.4 μg/dL and a TSH level of 6.3 mU/L. A radionuclide thyroid scanning indicates that the nodule has low radioactive iodine uptake. Which of the following is the most likely pathology to be found in this patient? ---- <<Choices:>> A) Anaplastic carcinoma B) Medullary carcinoma C) Reidel thyroiditis D) Silent thyroiditis ---- <<Answer:>>
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C
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<<Question:>> A researcher is testing an unknown compound, X, and seeing the effect it has on renal function. When she applies compound X to the cells, she finds that the urinary concentration of sodium and the pH decreases while the urinary potassium increases. Which of the following correctly states: 1) the cells of the kidney this compound acts on and 2) the identity of compound X? ---- <<Choices:>> A) Distal convoluted tubule; atrial natriuretic peptide B) Distal convoluted tubule; hydrochlorothiazide C) Principal cells; aldosterone D) Principal cells; spironolactone ---- <<Answer:>>
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C
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<<Question:>> A 5-year-old male is brought to the pediatrician with complaints of a painful mouth/gums, and vesicular lesions on the lips and buccal mucosa for the past 4 days. The patient has not been able to eat or drink due to the pain and has been irritable. The patient also reports muscle aches. His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%. Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy. Which of the following is the most likely causative organism in this patient's presentation? ---- <<Choices:>> A) CMV B) HIV C) HSV-1 D) HSV-2 ---- <<Answer:>>
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C
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<<Question:>> A patient is unresponsive in the emergency department following a motor vehicle accident. The patient's written advance directive states that he does not wish to be resuscitated in the event of a cardiac arrest. The patient's wife arrives and demands that "everything" be done to keep him alive because she "can't go on living without him." The patient's adult son is on his way to the hospital. If the patient arrests, which of the following should occur? ---- <<Choices:>> A) Respect the wife's wishes and resuscitate the patient B) Respect the patient's prior wishes and do not resuscitate C) Consult a judge for the final decision on whether or not to resuscitate D) Consult the hospital ethics committee ---- <<Answer:>>
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B
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<<Question:>> A 63-year-old man comes to the emergency department because of retrosternal chest pain. He describes it as 7 out of 10 in intensity. He has coronary artery disease, hypertension, and type 2 diabetes mellitus. His current medications are aspirin, simvastatin, metformin, and enalapril. He has smoked one pack of cigarettes daily for 33 years. On arrival, his pulse is 136/min and irregular, respirations are 20/min, and blood pressure is 85/55 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. An ECG is shown. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Coronary angiogram B) Intravenous esmolol C) Intravenous amiodarone D) Synchronized cardioversion ---- <<Answer:>>
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D
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<<Question:>> A 14-year-old boy presents with right upper quadrant abdominal pain and is found on ultrasound to have a gallstone. Based on clinical suspicion, a CBC, a Coombs test, and a bilirubin panel are obtained to determine the etiology of the gallstone. These tests reveal a mild normocytic anemia with associated reticulocytosis as well as an increased RDW. In addition there is an indirect hyperbilirubinemia and the Coombs test results are negative. To confirm the diagnosis, an osmotic fragility test is performed which shows increased fragility in hypotonic solution. In this patient, what findings would most likely be anticipated if a blood smear were obtained? ---- <<Choices:>> A) Hypersegmented neutrophils B) Sideroblasts C) Spherocytes D) Dacrocytes ---- <<Answer:>>
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C
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<<Question:>> A 32-year-old man comes to the physician because of a 2-day history of a tingling sensation in his right forearm. He reports that his symptoms started after he lifted heavy weights at the gym. Physical examination shows loss of sensation on the lateral side of the right forearm. Sensation over the thumb is intact. Range of motion of the neck is normal. His symptoms do not worsen with axial compression or distraction of the neck. Further examination of this patient is most likely to show weakness of which of the following actions? ---- <<Choices:>> A) Elbow flexion B) Forearm pronation C) Index finger flexion D) Wrist extension ---- <<Answer:>>
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A
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<<Question:>> A 30-year-old woman presents to your office with decreased appetite, malaise, and fever. Serologic tests reveal positive Anti-HBsAg and Anti-HAV IgM antibodies. Which of the following is most likely responsible for this patient's presentation? ---- <<Choices:>> A) Needlestick B) Unprotected sex C) Shellfish D) Acetaminophen overdose ---- <<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 63-year-old patient presents to the emergency department because of severe left leg pain and tingling. His condition started suddenly 30 minutes ago. He has had hypertension for the past 10 years for which he takes bisoprolol. He does not smoke or drink alcohol. His temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 100/min and irregular. On physical examination, the patient appears in severe pain and his left leg is pale and cool. The popliteal pulse is weaker on the left side compared to the right side. Which of the following is the most common cause of this patient's condition? ---- <<Choices:>> A) Vasculitis B) Hyperhomocysteinemia C) Arterial emboli D) Arterial trauma ---- <<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 brought to the pediatrician by her father for evaluation. He is concerned that she has not undergone puberty yet, while all of her classmates at school have. The patient herself feels well overall, with no specific complaints. Examination shows vital signs of T 98.9, HR 71, and BP 137/92. The physician notes undeveloped breasts and normal external and internal female genitalia in Tanner I stage of development. Her body mass index is within normal limits, she is in the 40th percentile for height, and she is agreeable and pleasant during the interview. Which of the following additional findings is likely present in this patient? ---- <<Choices:>> A) Aromatase enzyme deficiency B) Hypokalemia C) XY karyotype D) Hypercortisolism ---- <<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:>> Current recommendations state that a single hemoglobin A1c value of greater than 6.5% is diagnostic of diabetes mellitus. If this 6.5% cut-off is to be increased to 7.0%, which of the following would be true? ---- <<Choices:>> A) Increase in false negative test results B) Increase in false positive test results C) Decrease in true negative test results D) Increase in true positive test results ---- <<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:>> Patients with the diagnosis of sickle cell anemia make a specific type of hemoglobin known as HgbS. This mutation results in the sickling of their red blood cells when exposed to inciting factors such as hypoxic conditions. Patients are often treated with hydroxyurea, which has which of the following direct effects on their hemoglobin physiology? ---- <<Choices:>> A) Decreases oxygen carrying capacity of hemoglobin B) Increases levels of fetal hemoglobin (HgbF) C) Decreases levels of HgbS D) Decreases levels of fetal hemoglobin (HgbF) ---- <<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 40-year-old man presents to the emergency department with altered mental status. He has a history of cirrhosis of the liver secondary to alcoholism. He started becoming more confused a few days ago and it has been getting gradually worse. His temperature is 98.8°F (37.1°C), blood pressure is 134/90 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended abdomen that is non-tender. Neurological exam is notable for a confused patient and asterixis. Laboratory values are ordered as seen below. Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 3.3 mEq/L HCO3-: 22 mEq/L BUN: 20 mg/dL Glucose: 59 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL Which of the following is the best next treatment for this patient? ---- <<Choices:>> A) Dextrose B) Lactulose C) Potassium D) Rifaximin ---- <<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 previously healthy 4-month-old girl is brought to the emergency department by her parents because she has not stopped crying for the past 5 hours. Her parents report that she has not eaten anything during this period and that they were unable to calm her down. She has not had any trauma. She was born at term via vaginal delivery and her delivery was uncomplicated. Her vital signs are within normal limits. Examination shows a reddened and swollen 2nd toe of the left foot. A photograph of the left foot is shown. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Raynaud phenomenon B) Ingrown toe nail C) Hair tourniquet syndrome D) Herpetic whitlow ---- <<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 35-year-old woman presents to the physician because of episodes of difficulty swallowing for the past 3 months. She feels solid food getting stuck in her chest behind the sternum. She does not have any issues with liquids. She has no coughing or nasal regurgitation. She has no hoarseness or weight loss. She reports occasional heartburn that has lasted for about a year. Her past medical history is significant for asthma and eczema. She has no history of any serious illness and takes no medications. Her vital signs are within normal limits. Physical examination shows no abnormal findings. An endoscopic image of the esophagus is shown. Mucosal biopsy shows eosinophilic infiltration. Which of the following is the most appropriate pharmacotherapy at this time? ---- <<Choices:>> A) Budesonide B) Fluconazole C) Nitroglycerin D) Omeprazole ---- <<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 2-year-old boy in respiratory distress is brought to the emergency department by his parents. They state that approximately one hour after putting their child to sleep, a "hacking" cough was heard from his bedroom. After entering his room the parents state their child appeared to be in distress, making a high pitched noise with every breath. Beyond a runny nose for the past few days, the child has been healthy. He has no toys in his bed or access to any other small objects. Physical exam demonstrates a 2-year-old child in respiratory distress. Which of the following choices is the proper management for this patient? ---- <<Choices:>> A) Humidified oxygen and dexamethasone; discharge if the patient improves B) Dexamethasome, racemic epinephrine and observation for 4 hours; discharge if stridor remits C) Broncoscopy to remove a foreign body in the upper airway then discharge D) Empiric intravenous (IV) antibiotics, intubate and admission ---- <<Answer:>>
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B
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<<Question:>> A 70-year-old woman with no significant medical history begins to experience memory loss and personality changes. Over the next few months, her symptoms become more severe, as she experiences rapid mental deterioration. She also starts to have sudden, jerking movements in response to being startled and gait disturbances. Eventually, she lapses into a coma and dies eight months after the onset of symptoms. What process likely caused this woman's illness? ---- <<Choices:>> A) Loss of dopaminergic neurons in the substantia nigra pars compacta. B) Autoimmune inflammation and demyelination of the peripheral nervous system. C) Conversion of a protein from an a-helix to a ß-pleated form, which resists degradation. D) Frontotemporal atrophy and the accumulation of intracellular, aggregated tau protein. ---- <<Answer:>>
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C
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<<Question:>> A 38-year-old woman presents with eye dryness and a foreign body sensation in the eyes. On physical examination, the oral cavity shows mucosal ulceration and atrophy. Biopsy of the lower lip shows marked lymphocytic infiltration of the minor salivary glands. Which of the following is most likely seen in this patient? ---- <<Choices:>> A) Anti-Sjögren's syndrome type B (SS-B) antibody B) Anti-centromere antibody C) Anti-Jo-1 antibody D) Anti-Scl-70 antibodies ---- <<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 62-year-old man with a history of chronic bronchitis comes to the physician because of a 1-month history of worsening shortness of breath and cough productive of thick sputum. He smoked one pack of cigarettes daily for 20 years but quit 5 years ago. Physical examination shows an increased anteroposterior chest diameter and coarse crackles in the lower lung fields bilaterally. Treatment with a drug that directly antagonizes the effects of vagal stimulation on the airways is begun. Which of the following drugs was most likely started? ---- <<Choices:>> A) Fluticasone B) Montelukast C) Tiotropium D) Cromolyn ---- <<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 14-year-old boy is brought to the physician for evaluation of his sense of smell. Two days ago, his mother found that he had left the gas on in the kitchen, and he was unable to smell the odor of the gas. As a child, he was consistently in the 40th percentile for height; now he is in the 15th percentile. He had bilateral orchidopexy for cryptorchidism as an infant. The patient is unable to identify several common odors when presented with them. Physical examination shows sparse axillary and pubic hair and Tanner stage 1 genitals. Which of the following is the most likely underlying cause of the patient's condition? ---- <<Choices:>> A) Compression of pituitary stalk B) Hyperprolactinemia C) Impaired migration of GnRH neurons D) Decreased thyroxine production ---- <<Answer:>>
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C
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<<Question:>> A 26-year-old woman comes to the physician for a follow-up vaccination 1 week after being bitten by a rodent while camping. She received appropriate post-exposure prophylaxis in the emergency department and has already received 2 doses of the rabies vaccine. The same physician has been managing the post-exposure care regimen. After the physician administers the third dose of the rabies vaccine, the patient asks him if he would like to join her for a movie and dinner. The physician is interested in going on a date with her. Which of the following is the most appropriate reaction for the physician to have to the patient's invitation? ---- <<Choices:>> A) Inform the patient that romantic relationships with current patients are unethical. B) Inform the patient that he will go on a date with her because her case is uncomplicated and does not require decision-making on his part. C) Inform the patient that dating her will never be appropriate even once the physician-patient relationship has been terminated. D) Inform the patient that he will go on a date with her, but that she will have to transfer her care to a different physician. ---- <<Answer:>>
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A
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<<Question:>> A 38-year-old nursing home worker presents to the clinic with complaints of fever, loss of appetite, fatigue, and productive cough for the past couple of months. His fever is low-grade and sputum is often blood-tinged. He has lost 6.8 kg (15.0 lb) during this period and complains of profound night sweats. A plain radiograph of the patient’s chest shows consolidation in the apical part of the right lung. Baseline investigations show the following: Complete blood count Hemoglobin 11 g/dL White blood cells Total count 16,000/mm3 Differential count Neutrophils 35% Lymphocytes 54% Eosinophils 11% Erythrocyte sedimentation rate 84 mm The physician suspects that the patient is suffering from a chronic lung infection. Which of the following statements best describes the type of lung inflammation in this patient? ---- <<Choices:>> A) There are small granulomas with few epithelioid cells along with fibrosis. B) It has a granuloma with Anitchov cells around a core of fibrinoid collagen necrosis. C) It consists of a largely circumscribed granuloma with epithelioid cells with Langhans cells. D) This type of granulomatous inflammation is also seen in histoplasmosis. ---- <<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 16-year-old boy presents to the emergency department with shortness of breath after prolonged exposure to cold air during a recent hike with his friends. He informs the physician that he is asthmatic, but does not use inhalers regularly because he does not like using medications. He is a non-smoker and occasionally drinks alcohol. On physical examination, the temperature is 37.0°C (98.6°F), the pulse is 120/min, the blood pressure is 114/76 mm Hg, and the respiratory rate is 32/min. Auscultation of the chest reveals bilateral wheezing. The physician asks the nurse to administer nebulized albuterol; however, the boy declines nebulized albuterol because of a history of palpitations that he experienced previously. The physician then prescribes nebulized ipratropium bromide, which results in significant clinical improvement. Which of the following second messenger systems is affected by the drug that improved the boy's symptoms? ---- <<Choices:>> A) Cyclic guanosine monophosphate (cGMP) system B) Arachidonic acid system C) Phosphoinositol system D) Tyrosine kinase system ---- <<Answer:>>
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C
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<<Question:>> A 2050-g (4.5-lb) female newborn and a 2850-g (6.3-lb) female newborn are delivered at 37 weeks' gestation to a 23-year-old, gravida 2, para 1 woman. The mother had no prenatal care. Examination of the smaller newborn shows a flattened nose and left-sided clubfoot. The hematocrit is 42% for the smaller newborn and 71% for the larger newborn. This pregnancy was most likely which of the following? ---- <<Choices:>> A) Monochorionic-diamniotic monozygotic B) Dichorionic-diamniotic dizygotic C) Monochorionic-monoamniotic monozygotic D) Conjoined twins ---- <<Answer:>>
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A
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<<Question:>> A 55-year-old woman is found to have an abnormal mass on routine mammography. The mass is biopsied and cytology results are diagnostic for invasive ductal adenocarcinoma that is estrogen receptor positive. The patient is started on chemotherapy and ultimately has the mass resected. She is taking tamoxifen and has regular outpatient follow up appointments to monitor for any recurrence of cancer. The patient has a past medical history of asthma, obesity, and a uterine leimyoma which was definitively treated last year. Her last menstrual period was at the age of 47. The patient's vital signs and exam are unremarkable. Which of the following is a potential complication that could occur in this patient? ---- <<Choices:>> A) Deep venous thrombosis B) Eruption of seborrheic keratoses C) Increased bleeding D) Osteoporosis ---- <<Answer:>>
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A
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<<Question:>> A 24-year-old woman is brought to the physician because of agitation, confusion, and lethargy. She has also had progressive recurring headaches and visual impairment over the last month. Three days ago, she had a seizure but has not seen a physician. She is oriented only to person. Her temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Capillary refill time is more than 3 seconds. Her laboratory studies show: Hemoglobin 11.2 g/dL Leukocyte count 7000/mm3 Serum Na+ 148 mEq/L Cl- 100 mEq/L K+ 3.8 mEq/L HCO3- 26 mEq/L Urea nitrogen 18 mg/L Glucose 90 mg/L Creatinine 0.8 mg/L Osmolality 300 mOsmol/kg H2O Urine osmolality 240 mOsm/kg H2O Which of the following is the most likely explanation for this patient's hypernatremia?" ---- <<Choices:>> A) Increased water intake B) Increased adrenocorticotropin hormone secretion C) Decreased antidiuretic hormone secretion D) Decreased adrenocorticotropin hormone secretion ---- <<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 physician with a blurred vision of her right eye for 2 days. She has pain around her right eye during eye movement. She takes no medications. At the clinic, her blood pressure is 110/70 mm Hg, the pulse is 72/min, respirations are 15/min, and the temperature is 36.5℃ (97.7℉). On physical examination, illumination of the left eye results in bilateral pupillary constriction while illumination of the right eye results in a mild bilateral pupillary dilation. Fundoscopic examination shows optic disk swelling in the right eye. The color vision test shows decreased perception in the right eye. The remainder of the physical examination shows no abnormalities. Specific additional history should be obtained regarding which of the following? ---- <<Choices:>> A) Dry eyes B) High-risk sexual behaviour C) Oral ulcers D) Sensory loss ---- <<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 woman presents to her physician with complaints of cyclic vomiting for 3 days. The vomitus is watery and contains undigested food particles. She also complains of feeling tired and having the “sniffles”. She has not felt like eating or drinking since her symptoms started, and she has not taken any medications. Her concern now is that she immediately gets dizzy when she stands up. Vitals signs include: pulse 120/min, respiratory rate 9/min, and blood pressure 100/70 mm Hg. Her eyes are sunken, and her tongue appears dry. Which set of lab values would best correspond to this patient’s condition? ---- <<Choices:>> A) pH = 7.5, Pco2 = 50 mm Hg, HCO32- = 38 mEq/L B) pH = 7.2, Pco2 = 25 mm Hg, HCO32- = 30 mEq/L C) pH = 7.5, Pco2 = 34 mm Hg, HCO32- = 38 mEq/L D) pH = 7.5, Pco2 = 30 mm Hg, HCO32- = 24 mEq/L ---- <<Answer:>>
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A
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<<Question:>> A 30-year-old male presents to his primary care physician complaining of infertility. He and his wife have been trying to get pregnant for the past two years. They have used fertility monitors and other aids without success. A hysterosalpingogram in his wife was normal. The patient has a history of cleft lip and recurrent upper respiratory infections as a child. He was briefly hospitalized for severe pneumonia when he was 9-years-old. His temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 18/min. On examination, he is a healthy-appearing male in no acute distress with fully developed reproductive organs. Notably, cardiac auscultation is silent in the left 5th intercostal space at the midclavicular line. This patient most likely has a mutation in which of the following classes of proteins? ---- <<Choices:>> A) Microtubule monomeric protein B) Transmembrane ion channel protein C) Retrograde cytoskeletal motor protein D) Anterograde cytoskeletal motor protein ---- <<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 71-year-old woman with type 2 diabetes mellitus and hypertension comes to the emergency department because of a 3-day history of intermittent abdominal pain, vomiting, and obstipation. She has had multiple episodes of upper abdominal pain over the past year. She has smoked 1 pack of cigarettes daily for the past 30 years. Physical examination shows a distended abdomen with diffuse tenderness and high-pitched bowel sounds. An x-ray of the abdomen shows a dilated bowel, multiple air-fluid levels, and branching radiolucencies in the right infra-diaphragmatic region. Which of the following is the most likely cause of this patient's condition? ---- <<Choices:>> A) Perforation of the duodenal wall B) Inflammation of the gallbladder wall C) Obstruction of the common bile duct D) Torsion of the large intestine ---- <<Answer:>>
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B
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<<Question:>> A 36-year-old man undergoes open reduction and internal fixation of a left femur fracture sustained after a motor vehicle collision. Three days after the surgery, he develops fever and redness around the surgical site. His temperature is 39.5°C (103.1°F). Physical examination shows purulent discharge from the wound with erythema of the surrounding skin. Wound culture of the purulent discharge shows gram-positive cocci in clusters. Treatment with oral dicloxacillin is initiated. Four days later, the patient continues to have high-grade fever, pain, and purulent discharge. Which of the following characteristics of the infecting organism best explains the failure to improve with antibiotic therapy? ---- <<Choices:>> A) Presence of an impenetrable outer membrane B) Ability to cleave β-lactam rings C) Development of efflux pumps D) Adaptation in binding proteins ---- <<Answer:>>
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D
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<<Question:>> A 45-year-old woman comes into your office with complaints of "lump" she found on her neck while showering. She denies any other symptoms and states that she has not gained any weight. On exam, you notice a 2 cm nodule on her anterior neck. Her TSH level is normal and radionucleotide scan reveals a cold nodule. Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy. What is the next best step? ---- <<Choices:>> A) Punch biopsy B) Surgical excision C) Thyroxine administration D) Ultrasound ---- <<Answer:>>
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B
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<<Question:>> While in the ICU, a 62-year-old male undergoes placement of a Swan-Ganz catheter to evaluate his right heart pressures. All pressures are found to be within normal limits, and the cardiology fellow records a pulmonary wedge pressure of 10 mmHg. Which of the following are normal values for the pressures that will be obtained from this patient's right ventricle? ---- <<Choices:>> A) 25/10 mmHg B) 25/5 mmHg C) 10/0 mmHg D) 100/70 mmHg ---- <<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 3-year-old boy is brought to the physician for a well-child examination. Over the past 8 months, his mother reports difficulty understanding the boy's speech. On occasion during this period, she has noticed that he does not respond when called by name and cannot follow 1-step instructions. He has a history of recurrent ear infections treated with antibiotics since birth. He is at the 60th percentile for length and 50th percentile for weight. Vital signs are within normal limits. His speech is quiet and difficult to understand. Otoscopic examination shows retracted tympanic membranes bilaterally that are immobile on pneumatic otoscopy. Nasopharyngoscopy shows mild adenoid hypertrophy. Pure tone audiometry shows a conductive hearing loss of 26 dB on the right side and 28 dB on the left side. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Adenoidectomy B) Tympanostomy tube insertion C) Antihistamine therapy D) Corticosteroid 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 42-year-old man is admitted to the intensive care unit with decreased consciousness and convulsions. His wife reports that 30 min following the onset of her husband’s condition, which started approximately 6 hours ago, he treated his garden bed with pesticides against mice. He developed nausea, vomiting, and abdominal cramps. The patient noted facial muscle twitching and developed a tonic-clonic seizure that lasted 3 minutes, 4 hours following the onset of his condition. His past medical history is insignificant for any seizure disorders, and he does not take any medications. His blood pressure is 95/60 mm Hg, heart rate is 104/min, respiratory rate is 10/min, and the temperature is 37.0°C (98.6°F). On physical examination, the patient’s consciousness is decreased with a Glasgow Coma Scale score of 13. He is pale and sweaty. His lung sounds are normal, cardiac sounds are decreased, and no murmurs are present. Abdominal palpation reveals epigastric tenderness. Neurological examination shows rapid downbeating nystagmus, facial muscle twitching, and symmetrically decreased sensation to all the sensory modalities on both the upper and lower extremities. Further discussion reveals that the patient was using sodium fluoroacetate as a pesticide, which is known to form fluorocitrate in the cells of aerobic organisms. Which of the following substances will accumulate in the patient’s cells? ---- <<Choices:>> A) Fumarate B) Citrate C) Malate D) Succinate ---- <<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 72-year-old woman presents to the emergency department with altered mental status. 90 minutes ago, the patient was found by a neighbor unarousable on the couch with multiple empty bottles of medication on the floor next to her. Social history is significant for alcohol abuse. Physical examination reveals an awake female with a fluctuating level of consciousness, not oriented to time or place. No focal neurologic deficits. Which of the following additional findings would most likely be present in this patient? ---- <<Choices:>> A) Hallucinations B) Irreversibility C) Multi-infarct dementia D) Normal vital signs ---- <<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 emergency department because of a cough, dyspnea, and fever for 1 day. The cough is productive of small amounts of green phlegm. He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago. He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year. His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler. He has smoked one pack of cigarettes daily for 48 years. His temperature is 39.1°C (103.1°F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Pulmonary examination shows diffuse crackles and rhonchi. An x-ray of the chest shows a left upper-lobe infiltrate of the lung. Two sets of blood cultures are obtained. Endotracheal aspirate Gram stain shows gram-negative rods. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate pharmacotherapy? ---- <<Choices:>> A) Ceftriaxone and azithromycin B) Ertapenem C) Colistin D) Cefepime and levofloxacin ---- <<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 21-year-old old college student is brought to the emergency department by his roommates because he has been "acting strangely." Over the last 7 months, he has claimed to hear voices telling him that he must prepare for the end of the world. He used to be a straight A student but started failing exams recently due to his erratic behavior. Furthermore, there are periods of time where he does not sleep for several days and redecorates the entire apartment. During those times he spends huge amounts of money on online shopping. These periods usually last for about 2 weeks and happen every other month. On physical exam, he appears unkept and irritated. He seems to respond to invisible stimuli, and he jumps from topic to topic without clear focus. Which of the following is most consistent with this patient's presentation? ---- <<Choices:>> A) Brief psychotic disorder B) Schizoaffective disorder C) Schizophreniform disorder D) Schizotypal personality disorder ---- <<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:>> An 81-year-old man is brought to the clinic by his son to be evaluated for memory issues. The patient’s son says he has difficulty remembering recent events and names. He says the patient’s symptoms have progressively worsened over the last several years but became acutely worse just recently. Also, yesterday, the patient complained that he could not see out of his right eye, but today he can. When asked about these concerns, the patient seems to have no insight into the problem and reports feeling well. His medical history is significant for diabetes mellitus type 2 and hypertension. He had a left basal ganglia hemorrhage 12 years ago and a right middle cerebral artery infarction 4 years ago. Current medications are amlodipine, aspirin, clopidogrel, metformin, sitagliptin, and valsartan. He lives with his son and can feed himself and change his clothes. There is no history of urinary or fecal incontinence. His vitals include: blood pressure 137/82 mm Hg, pulse 78/min, respiratory rate 16/min, temperature 37.0°C (98.6°F). On physical examination, the patient is alert and oriented. He is unable to perform simple arithmetic calculations and the mini-mental status exam is inconclusive. He can write his name and comprehend written instructions. Muscle strength is 4/5 on the right side. The tone is also slightly reduced on the right side with exaggerated reflexes. His gait is hemiparetic. Which of the following is the most likely diagnosis in this patient? ---- <<Choices:>> A) Alzheimer's disease B) Lewy body dementia C) Normal-pressure hydrocephalus D) Vascular dementia ---- <<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 46-year-old woman with a history of previously well-controlled HIV infection comes to the physician for follow-up after a health maintenance examination last week. She is currently unemployed and lives in a low-income neighborhood with her 3 children. For the past 3 years, her HIV RNA viral load was undetectable, but last week, her viral load was 8,391 copies/mL (N < 50). Current medications include dolutegravir, tenofovir, and emtricitabine. On questioning, she says that she misses her medications every other day. Which of the following responses by the physician is most appropriate? ---- <<Choices:>> A) """Let's talk about what makes it difficult for you to take your medications.""" B) """Are you aware that it is essential to take your medications every day?""" C) """The social worker can help subsidize next month's medications.""" D) """We should go over the instructions on how to take your medications again.""" ---- <<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 comes to the physician for a routine medical check-up prior to a scheduled elective femoropopliteal bypass surgery of his left leg. He feels well but reports occasional episodes of weakness and numbness in his left hand. He has a history of peripheral arterial disease, type 2 diabetes mellitus, hypertension, hypercholesterolemia, and gout. The patient has smoked 1 pack of cigarettes daily for the past 50 years. He drinks 3 cans of beer daily. His current medications include aspirin, metformin, enalapril, simvastatin, and febuxostat. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 122/76 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Auscultation of the right side of the neck shows a bruit. There is a right-sided reducible inguinal hernia. Neurological examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, and glucose are within the reference ranges. An electrocardiogram shows signs of mild left ventricular hypertrophy. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) Ultrasonography of the neck B) Echocardiography C) Warfarin therapy D) CT angiography of the head ---- <<Answer:>>
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A
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<<Question:>> A 35-year-old woman presents to her primary care provider concerned that she may be pregnant. She has a history of regular menstruation every 4 weeks that lasts about 4 days with mild to moderate bleeding, but she missed her last period 2 weeks ago. A home pregnancy test was positive. She has a 6-year history of hyperthyroidism that is well-controlled with daily methimazole. She is currently asymptomatic and has no complaints or concerns. A blood specimen is taken and confirms the diagnosis. Additionally, her thyroid-stimulating hormone (TSH) is 2.0 μU/mL. Which of the following is the next best step in the management of this patient? ---- <<Choices:>> A) Continue methimazole B) Discontinue methimazole, start propylthiouracil C) Add glucocorticoids D) Refer for 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 65-year-old man presents to the emergency department with back pain. The patient states that he has gradually worsening back pain that seems to have worsened after moving furniture the other day. He also states that while he walks, he feels numbness and weakness in his legs. The only time the patient states his back pain is improved is when he is riding his bike or pushing a cart at the grocery store. The patient has a past medical history of osteoporosis, dyslipidemia, and diabetes. He drinks 3 alcoholic drinks every day and has a 44 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 157/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-tender spine with normal mobility in all 4 directions. Radiography of the spine and basic labs are ordered. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Compression fracture B) Herniated nucleus pulposus C) Musculoskeletal strain D) Spinal stenosis ---- <<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 3-year-old girl is brought to the physician because of a 3-day history of fever, cough, purulent nasal discharge. She has experienced 7 similar episodes, each lasting 2–5 days in the previous 2 years. She has also had intermittent abdominal cramps and recurrent episodes of foul-smelling greasy diarrhea in the past year. She is at the 55th percentile for height and 35th percentile for weight. Her temperature is 38.9°C (102°F), pulse is 100/min, respirations are 24/min, and blood pressure is 110/60 mm Hg. Physical examination shows an erythematous oropharynx without exudate and tenderness over the frontoethmoidal sinuses. The abdomen is distended, nontender, and tympanitic to percussion. Bowel sounds are increased. Stool microscopy shows pear-shaped multi-flagellated organisms. This patient is at increased risk for which of the following? ---- <<Choices:>> A) Anaphylactic transfusion reactions B) Cutaneous granulomas C) Non-Hodgkin lymphoma D) Disseminated tuberculosis ---- <<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 8-year-old boy who recently immigrated to the United States presents with a rash. Past medical history is significant for a recent sore throat which caused him to miss several days at school. The patient’s vaccination status is unknown. On physical examination, the patient is pale and ill-looking. There are pink rings present on the torso and inner surfaces of the limbs. Cardiac exam is significant for a holosystolic murmur heard best over the apex of the heart. Which of the following histopathologic findings is most likely associated with this patient’s condition? ---- <<Choices:>> A) Atypical lymphocytes on peripheral blood smear B) Starry sky appearance C) Needle-shaped, negatively birefringent crystal deposits D) Granulomas with giant cells ---- <<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 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram. His vitals signs are stable, with blood pressure 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable. If this patient's cough is due to one of the medications he is taking, what would be the next step in management? ---- <<Choices:>> A) Change lisinopril to propanolol B) Change lisinopril to amlodipine C) Change atorvastatin to to lovastatin D) Change lisinopril to losartan ---- <<Answer:>>
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D
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<<Question:>> A male newborn is evaluated 24 hours after delivery for high-pitched crying, poor feeding, rhinorrhea, and low-grade fever. He was born at 40 weeks' gestation at 2514 g (5.54 lb) to a 28-year-old woman, gravida 3, para 2, by an uncomplicated cesarean section. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The mother did not receive prenatal care. The infant's temperature is 38.0°C (100.4°F), pulse is 170/min, and blood pressure is 71/39 mm Hg. Examination shows hyperreflexia, tremors, and an excessive startle response. These symptoms are mostly like due to maternal use of which of the following? ---- <<Choices:>> A) Mu receptor agonist B) Nicotinic acetylcholine receptor agonist C) Monoamine reuptake antagonist D) Thyroperoxidase inhibitor ---- <<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 previously healthy 35-year-old primigravid woman at 12 weeks' gestation comes to the physician because of a fever, persistent headache, nausea, and abdominal discomfort for 1 week. During this time, she has also noticed that her gums bleed while brushing her teeth. A month ago, she returned from a camping trip to Sri Lanka. Her temperature is 39.3°C (102.8°F), pulse is 104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg. Examination shows pallor and mild scleral icterus. There are a few scattered petechiae over the trunk and back. There is no lymphadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show: Hemoglobin 8.2 g/dL Leukocyte count 10,000/mm3 Platelet count 18,000/mm3 INR 1.0 Coomb's test negative Fibrin split products negative Serum Urea 20 mg/dL Creatinine 1.1 mg/dL Bilirubin Total 3.0 mg/dL Direct 0.8 mg/dL Alanine aminotransferase 20 U/L Aspartate aminotransferase 16 U/L Lactate dehydrogenase 900 U/L Urine Protein 1+ WBCs occasional RBCs 50–60/hpf Bacteria nil A photograph of the peripheral blood smear is shown. Blood and urine cultures are negative. Which of the following is the most likely diagnosis?" ---- <<Choices:>> A) HELLP syndrome B) Thrombotic thrombocytopenic purpura C) Hemolytic uremic syndrome D) Autoimmune hemolytic anemia " ---- <<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 36-year-old man is brought to the emergency department 40 minutes after being involved in a shooting. He sustained a gunshot wound in an altercation outside of a bar. On arrival, he is oriented to person but not to place or time. His temperature is 37.3°C (99.1°F), pulse is 116/min, respirations are 18/min, and blood pressure is 79/42 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows multiple abrasions over the arms and thorax. There is a 1-cm (0.4-in) entry wound with minimal bleeding on the right side of the chest in the 6th intercostal space at the midclavicular line. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows diffuse mild tenderness to palpation with no guarding or rebound. A focused assessment with sonography shows no obvious free fluid in the pericardium; assessment of the abdomen is equivocal. An x-ray of the chest shows mild opacification of the right lower lobe. Two large-bore cannulas are inserted and intravenous fluid resuscitation is begun. The patient is intubated and mechanical ventilation is begun. Which of the following is the most appropriate next step in management? ---- <<Choices:>> A) CT scan of the chest, abdomen, and pelvis B) Local wound exploration C) Exploratory laparotomy D) Video-assisted thoracoscopic surgery ---- <<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:>> Mutations in the ATP2A1 gene results in loss of function of the calcium ATPase pump, which is in the sarcoplasmic reticulum membranes of skeletal muscle in humans. This mutation results in a rare disease characterized by muscle cramping and stiffening that is usually most severe after exercise or strenuous activity and is typically relieved after affected individuals rest for a few minutes. Which of the following is expected in individuals with an ATP2A1 gene mutation? ---- <<Choices:>> A) Muscle relaxation time: decreased, cytosolic calcium concentration: increased B) Muscle relaxation time: increased, cytosolic calcium concentration: increased C) Muscle relaxation time: increased, cytosolic calcium concentration: no change D) Muscle relaxation time: no change, cytosolic calcium concentration: decreased ---- <<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 62-year-old man presents to the emergency department with crushing chest pain (10/10 in severity), radiating to the left side of the neck and the left arm. His symptoms started 20 minutes ago while shaving. He also feels nauseated, lightheaded and short of breath. He has had type 2 diabetes for 27 years and essential hypertension for 19 years. He has smoked 20–30 cigarettes per day for the past 35 years. Family history is irrelevant. His temperature is 36.9°C (98.4°F), the blood pressure is 115/72 mm Hg and the pulse is 107/min. Physical examination is unremarkable. ECG is shown in the image. Troponins are elevated. The patient is admitted to a unit with continuous cardiac monitoring. Aspirin, clopidogrel, sublingual nitroglycerin, and morphine are given immediately and the patient now rates the pain as 4–5 out of 10. Which of the following is the best next step in the management of this patient condition? ---- <<Choices:>> A) Percutaneous coronary intervention B) Intravenous alteplase C) Coronary artery bypass graft D) Oral ramipril ---- <<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 54-year-old man comes to the emergency department because of a 2-day history of increasingly severe abdominal pain, nausea, and bilious vomiting. His last bowel movement was yesterday and he has not passed flatus since then. He underwent appendectomy at the age of 39. He has psoriasis, hypertension, type 2 diabetes mellitus, and chronic back pain. He drinks two beers daily. He takes a topical corticosteroid, ramipril, metformin, and ibuprofen daily. He is 176 cm (5 ft 9 in) tall and weighs 108 kg (240 lb); BMI is 35.4 kg/m2. His temperature is 36.8°C (98.4°F), respirations are 15/min, pulse is 90/min, and blood pressure is 112/67 mm Hg. Examination shows thick, scaly, plaques over both elbows and knees. Abdominal examination shows three well-healed laparoscopic scars. The abdomen is distended and there are frequent, high-pitched bowel sounds on auscultation. Digital rectal examination shows an empty rectum. Laboratory studies show: Hematocrit 44% Leukocyte count 9,000/mm3 Platelet count 225,000/mm3 Serum Na+ 139 mEq/L K+ 4.1 mEq/L Cl− 101 mEq/L HCO3− 26 mEq/L Glucose 95 mg/dL Creatinine 1.1 mg/dL Alkaline phosphatase 78 U/L Aspartate aminotransferase (AST, GOT) 19 U/L Alanine aminotransferase (ALT, GPT) 14 U/L γ-Glutamyltransferase (GGT) 52 U/L (N=5–50 U/L) Hemoglobin A1C 6.4% Abdominal ultrasound shows nonpropulsive peristalsis of the small bowel. Which of the following is the most likely cause of this patient's condition?" ---- <<Choices:>> A) Chronic inflammatory bowel disease B) Ibuprofen C) History of abdominal surgery D) Alcohol ---- <<Answer:>>
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C
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<<Question:>> A 28-year-old Caucasian woman presents to your office with recurrent abdominal cramping on her left side for 6 months. She additionally reports bloody diarrhea and tenesmus. You suspect ulcerative colitis. Which of the following findings would most strongly confirm your diagnosis? ---- <<Choices:>> A) Involvement of terminal ileum B) Noncaseating granulomas C) Transmural inflammation D) Continuous mucosal damage ---- <<Answer:>>
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D
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<<Question:>> A 6-month-old boy is brought to the physician by his parents for difficulty breathing and bluish discoloration of the lips for the past hour. During the past 3 months, the patient has had several upper respiratory tract infections and poor weight gain. Physical examination shows crackles over both lung fields and enlargement of the tonsils and cervical lymph nodes. His serum IgA, IgE, and IgG titers are decreased. An x-ray of the chest shows bilateral interstitial infiltrates. Methenamine silver staining of bronchial lavage fluid shows disc-shaped cysts. A defect in which of the following is the most likely underlying cause of this patient's condition? ---- <<Choices:>> A) Actin filament assembly B) T-cell receptor signaling C) Microtubule polymerization D) B-cell maturation ---- <<Answer:>>
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B
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<<Question:>> A 67-year-old man comes to the clinic complaining of fatigue and dizziness for the past 2 months. He reports that he gets tired easily compared to his baseline and feels dizzy when he exerts himself (e.g., when he walks long distances). His past medical history is significant for hypertension that is controlled with lisinopril. A physical examination demonstrates moderate hepatomegaly and lymphadenopathy. His laboratory studies are shown below. Leukocyte count and differential: Leukocyte count: 11,500/mm^3 Segmented neutrophils: 40% Bands: 3% Eosinophils: 1% Basophils: 0% Lymphocytes: 50% Monocytes: 8% Hemoglobin: 11.2 g/dL Platelet count: 120,000/mm^3 Mean corpuscular hemoglobin concentration: 31% Mean corpuscular volume: 80 µm^3 Reticulocyte count: 3% Lactate dehydrogenase: 45 U/L A subsequent flow cytometry test demonstrates CD20+ cells. What is the most likely finding you would expect in this patient? ---- <<Choices:>> A) Low levels of erythropoietin B) Low levels of leukocyte alkaline phosphatase (LAP) C) Presence of hairy cells D) Presence of smudge cells ---- <<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 81-year-old man is brought to the emergency department after he fell asleep at the dinner table and was not able to be roused by his family. His past medical history is significant for Alzheimer disease though he is still relatively functional at baseline. He has also been taking warfarin over the last 3 months after he suffered a deep venous thrombosis. After he was transported to the ED, his family found that the pills his grandson takes for seizures were missing. On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus. After determining the cause of this patient's symptoms, his physicians begin monitoring his international normalized ratio, because they are concerned that it will start trending down. Which of the following treatments would most improve the urinary excretion of the substance likely responsible for these symptoms? ---- <<Choices:>> A) Ammonium chloride B) Mannitol C) Sodium bicarbonate D) Thiazide diuretics ---- <<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 10-year-old girl is brought to the physician because of high-grade fever, myalgia, and generalized fatigue for 3 days. She returned from a vacation to northern Brazil 4 days ago. She took the appropriate medications and immunizations prior to her visit. There is no family history of serious illness. She appears ill. Her temperature is 39.4°C (103°F), pulse is 110/min and blood pressure is 94/54 mm Hg. Examination shows jaundice of the conjunctivae and skin. The abdomen is soft and nontender; the spleen is palpated 2 to 3 cm below the left costal margin. Laboratory studies show: Hemoglobin 10.1 g/dL Leukocyte count 4,650/mm3 Platelet count 200,000/mm3 Serum Glucose 56 mg/dL Creatinine 0.8 mg/dL Bilirubin Total 4.7 mg/dL Direct 0.9 mg/dL Lactate dehydrogenase 212 U/L Which of the following is the most likely to confirm the diagnosis?" ---- <<Choices:>> A) Thick and thin blood smear B) Direct antiglobulin test C) Sickle cell test D) Ultrasound of the abdomen ---- <<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 woman presents to a physician with severe pain and swelling of the left inguinal area for 3 days. She has a fever and malaise. Last week she noted several painless red papules on her left thigh when she was on a summer trip to Madagascar. She has no history of serious illnesses and is on no medications. There has been no recent contact with any animals or pets. The temperature is 38.6℃ (101.5℉), the pulse is 78/min, the respiration rate is 12/min, and the blood pressure is 110/65 mm Hg. Swelling of the left inguinal area was noted; however, there were no skin changes. Several large, tense, and tender lymph nodes with a boggy consistency were palpated in the inguinal region. The right inguinal area is normal on physical exam. There was no lymphadenopathy in other areas. No abnormalities existed in the lungs, heart, and abdomen. Microscopic examination of pus from the inguinal lymph nodes revealed gram-negative Coccobacilli. Serum anti-F1 titers show a 4-fold rise. Which of the following is the most appropriate pharmacotherapy at this time? ---- <<Choices:>> A) Azithromycin B) Imipenem C) Streptomycin D) No pharmacotherapy ---- <<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 emergency department because of sudden, painless loss of vision in her right eye that occurred 30 minutes ago while watching TV. She has coronary artery disease, hypertension, and type 2 diabetes mellitus; she has had trouble adhering to her medication regimen. Her blood pressure is 160/85 mm Hg. Examination shows 20/50 vision in the left eye and no perception of light in the right eye. Direct pupillary reflex is present in the left eye, but absent in the right eye. Accommodation is intact bilaterally. Intraocular pressure is 16 mm Hg in the left eye and 18 mm Hg in the right eye. Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula. The optic disc appears normal. Which of the following is the most likely diagnosis? ---- <<Choices:>> A) Retinal detachment B) Central retinal artery occlusion C) Acute angle-closure glaucoma D) Anterior ischemic optic neuropathy ---- <<Answer:>>
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B
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<<Question:>> A previously healthy 35-year-old woman comes to the emergency department because of sudden weakness of her right arm and leg that started 3 hours ago. She returned from a business trip from Europe 3 days ago. She has smoked a pack of cigarettes daily for 10 years. Her only medication is an oral contraceptive. Her temperature is 38.0°C (100.4°F), pulse is 115/min and regular, and blood pressure is 155/85 mm Hg. Examination shows decreased muscle strength on the entire right side. Deep tendon reflexes are 4+ on the right. Babinski sign is present on the right. The left lower leg is swollen, erythematous, and tender to palpation. Further evaluation is most likely to show which of the following? ---- <<Choices:>> A) Patent foramen ovale B) Mitral valve vegetation C) Atrial fibrillation D) Carotid artery dissection ---- <<Answer:>>
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A
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<<Question:>> A 24-year-old woman is brought to the emergency room (ER) by her co-workers after they found her unconscious in her cubicle when they returned from lunch. They tell you that she has diabetes but do not know anything more about her condition. The woman’s vital signs include: pulse 110/min, respiratory rate 24/min, temperature 36.7°C (98.0°F), and blood pressure 90/60 mm Hg. On physical examination, the patient is breathing heavily and gives irrelevant responses to questions. The skin and mucous membranes appear dry. Examination of the abdomen reveals mild diffuse tenderness to palpation. Deep tendon reflexes in the extremities are 1+ bilaterally. Laboratory studies show: Finger stick glucose 630 mg/dL Arterial blood gas analysis: pH 7.1 PO2 90 mm Hg PCO2 33 mm Hg HCO3 8 mEq/L Serum: Sodium 135 mEq/L Potassium 3.1 mEq/L Chloride 136 mEq/L Blood urea nitrogen 20 mg/dL Serum creatinine 1.2 mg/dL Urine examination shows: Glucose Positive Ketones Positive Leukocytes Negative Nitrite Negative RBCs Negative Casts Negative The patient is immediately started on a bolus of intravenous (IV) 0.9% sodium chloride (NaCl). Which of the following is the next best step in the management of this patient? ---- <<Choices:>> A) Infuse NaHCO3 slowly B) Switch fluids to 0.45% NaCl C) Start IV insulin infusion D) Replace potassium intravenously ---- <<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 38-year-old man is brought to the emergency room by his father because of altered mental status. According to the father, the patient was unable to get out of bed that morning and has become increasingly confused over the past several hours. The father also noticed it was “pretty cold” in his son's apartment because all of the windows were left open overnight. He has a history of hypothyroidism, schizoaffective disorder, type 2 diabetes mellitus, dyslipidemia, and hypertension for which he takes medication. Ten days ago, he was started on a new drug. He appears lethargic. His rectal temperature is 32°C (89.6°F), pulse is 54/min, respirations are 8/min, and blood pressure is 122/80 mm Hg. Examination shows weakness in the lower extremities with absent deep tendon reflexes. Deep tendon reflexes are 1+ in the upper extremities. The pupils are dilated and poorly reactive to light. Throughout the examination, the patient attempts to remove his clothing. Which of the following drugs is the most likely cause of these findings? ---- <<Choices:>> A) Lisinopril B) Fluphenazine C) Levothyroxine D) Atorvastatin " ---- <<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 36-year-old woman presents with increased tiredness and lethargy for the past 4 weeks. Investigations show her hemoglobin level to be 8.6 gm/dL and serum creatinine of 4.6 mg/dL. The serum is negative for antinuclear antibodies (ANA) and positive for C3 nephritic factor. Urinalysis shows a 3+ proteinuria. The renal biopsy demonstrates hypercellular glomerulus with electron dense deposits along the glomerular basement membrane. What is the most likely cause? ---- <<Choices:>> A) Membrano proliferative glomerulonephritis (MPGN) B) Rapidly progressive glomerulonephritis (RPGN) C) Minimal change disease D) Membranous glomerulonephritis (MGN) ---- <<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 48-year-old man is brought to the emergency department for sudden onset of difficulty breathing 6 hours ago. For the past several months, he has had shortness of breath on exertion and while lying down on the bed, frequent headaches, and swelling of his feet. He does not take any medications despite being diagnosed with hypertension 10 years ago. His pulse is 90/min, respirations are 20/min, blood pressure is 150/110 mm Hg, and temperature is 37.0°C (98.6°F). Physical examination shows an overweight male in acute distress with audible wheezes. Crackles are heard bilaterally and are loudest at the lung bases. Which of the following findings on cardiac auscultation will most likely be present in this patient? ---- <<Choices:>> A) Loud P2 B) S3 gallop C) Absent S4 D) A loud S1 ---- <<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:>> Please refer to the summary above to answer this question A medical student is examining the table in the abstract. She notices that the standard error surrounding measurements in the pulmharkimab 150 mg/day group is generally greater than the standard errors for the placebo and pulmharkimab 75 mg/day groups. Which of the following statements is the best explanation for the increased standard error in the pulmharkimab 150 mg/day group?" "Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma Introduction: Active asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors. It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease. This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression. Methods: In this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA. Patients who were immunocompromised or had a history of recurrent infections were excluded. Patients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants. All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence. Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms. Plaque volume was determined by ultrasound. Analyses were performed from baseline to month 12. Results: At baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all). A total of 215 participants (18%) were lost to follow-up. At 12-month follow-up, the groups contained the following numbers of participants: Pulmharkimab 75 mg/d: 388 participants Pulmharkimab 150 mg/d: 202 participants Placebo: 395 participants Table 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes. Models were adjusted for sociodemographic variables and medical comorbidities. All outcome variables were approximately normally distributed. Pulmharkimab 75 mg/d, (Mean +/- 2 SE) Pulmharkimab 150 mg/d, (Mean +/- 2 SE) Placebo, (Mean +/- 2 SE) P-value Plaque volume (mm3), change from baseline 6.6 ± 2.8 1.2 ± 4.7 15.8 ± 2.9 < 0.01 LDL-C levels, change from baseline -9.4 ± 3.6 -11.2 ± 14.3 -8.4 ± 3.9 0.28 FEV1/FVC ratio, change from baseline 0.29 ± 2.21 0.34 ± 5.54 -0.22 ± 3.21 0.27 ACQ scores, change from baseline 0.31 ± 1.22 0.46 ± 3.25 0.12 ± 1.33 0.43 Conclusion: Pulmharkimab may be effective in reducing plaque volume but does not lead to improved asthma control in patients with a history of myocardial infarction and comorbid asthma. Source of funding: Southeast Institute for Advanced Lung and Cardiovascular Studies, American Center for Advancement of Cardiovascular Health" ---- <<Choices:>> A) It indicates decreased external validity B) It indicates a lack of statistical significance C) It reflects a smaller sample size D) It indicates more narrow confidence intervals ---- <<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 63-year-old man with diverticular disease comes to the emergency department because of painless rectal bleeding, dizziness, and lightheadedness for 2 hours. His temperature is 37.6°C (99.6°F), pulse is 115/min, respirations are 24/min, and blood pressure is 86/60 mm Hg. He appears pale. Physical examination shows bright red rectal bleeding. Colonoscopy shows profuse diverticular bleeding; endoscopic hemostasis is performed. After initiating fluid resuscitation, the patient becomes hemodynamically stable. The following day, laboratory studies show: Hemoglobin 8 g/dL Leukocyte count 15,500/mm3 Platelet count 170,000/mm3 Serum Urea nitrogen 60 mg/dL Creatinine 2.1 mg/dL Bilirubin Total 1.2 mg/dL Indirect 0.3 mg/dL Alkaline phosphatase 96 U/L Alanine aminotransferase (ALT, GPT) 2,674 U/L Aspartate aminotransferase (AST, GOT) 2,254 U/L Which of the following cells in the patient's liver were most likely damaged first?" ---- <<Choices:>> A) Periportal hepatocytes B) Hepatic sinusoidal endothelial cells C) Hepatic Kupffer cells D) Centrilobular hepatocytes ---- <<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 32-year-old man is brought by ambulance to the emergency room after being involved in a head-on motor vehicle collision at high speed. The patient was found unconscious by the paramedics and regained consciousness briefly during the ambulance ride. Upon arrival at the hospital, the patient’s vitals show: pulse 110/min, respiratory rate 12/min, blood pressure 100/70 mm Hg, and oxygen saturation of 96%. Physical examination reveals an unresponsive man with multiple bruises across the chest and along the upper arms with a laceration on the forehead. His is unresponsive to verbal commands and physical touch. His GCS is 6/15. The right pupil is fixed and dilated. An urgent noncontrast CT of the head is performed and shown in the image. The patient is prepared for emergency neurosurgery. Which of the following anesthesia medications would be the best option for this patient? ---- <<Choices:>> A) Propofol B) Midazolam C) Nitrous oxide D) Sevoflurane ---- <<Answer:>>
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A
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<<Question:>> A 25-year-old female presents to urgent care with complaints of one day of burning and pain with urination, urgency, and frequency. She denies having a fever but has experienced intermittent chills. She is sexually active and inconsistently uses condoms. The patient has no past medical history. She is allergic to sulfa drugs. Physical examination of the genitalia is normal. Urinalysis shows positive leukocyte esterase and nitrites. The urine culture demonstrates gram-negative rods that form pink colonies on MacConkey agar. She is treated with an antibiotic and her symptoms quickly improve. The mechanism of the antibiotic she was most likely treated with is which of the following? ---- <<Choices:>> A) Inhibits cell wall synthesis B) Binds D-ala D-ala in the cell wall C) Inhibits initiation complex D) Inhibits sterol synthesis ---- <<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 70-year-old man with a history of hypertension and atrial fibrillation comes to the physician for shortness of breath with mild exertion, progressive weakness, and a dry cough that has persisted for 6 months. He has smoked a pack of cigarettes daily for 45 years. His medications include warfarin, enalapril, and amiodarone. His pulse is 85/min and irregularly irregular. Physical examination shows enlarged fingertips and markedly curved nails. A CT scan of the chest shows clustered air spaces and reticular opacities in the basal parts of the lung. Which of the following is the most likely underlying mechanism of this patient's dyspnea? ---- <<Choices:>> A) Chronic airway inflammation B) Bronchial hyperresponsiveness and obstruction C) Pleural scarring D) Excess collagen deposition in the extracellular matrix of the lung ---- <<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 21-year-old man is brought to the emergency department by his mother after being found lying unconscious next to a bottle of pills. The patient’s mother mentions that he has been diagnosed with major depressive disorder 3 years ago for which he was taking a medication that resulted in only a slight improvement in his symptoms. She says he still found it difficult to concentrate on his studies and did not participate in any social events in college. He didn’t have many friends and was often found sitting alone in his room. He has also threatened to take his life on several occasions, but she did not think he was serious. While recording his vital signs, the patient goes into a coma. His ECG shows a QT interval of 450 milliseconds. Which of the following medications did this patient most likely overdose on? ---- <<Choices:>> A) Bupropion B) Sertraline C) Venlafaxine D) Clomipramine ---- <<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:>> In a study to determine the risk factors for myocardial infarction (MI) at a young age (age < 30 years), 30 young patients with the condition are recruited into the study group. Sixty similar but healthy individuals are recruited into the control group. Educational status is considered to be an important variable, as it would affect the awareness of the disease and its risk factors among the participants. Based on the level of education, 2 groups are formed: low educational status and high educational status. A chi-square test is performed to test the significance of the relationship, and an odds ratio of 2.1 was computed for the association between low education and the risk of MI, with a confidence interval of 0.9–9.7. What inference can be made on the association between young age MI and educational status from this study? ---- <<Choices:>> A) The association is not statistically significant, and low education is not a risk factor. B) The association is statistically significant, but low education is not a risk factor. C) The association is not statistically significant, but low education is a risk factor. D) One can not comment, as the p-value is not given. ---- <<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 32-year-old primigravid woman at 16 weeks' gestation comes to the physician for a routine prenatal visit. She is asymptomatic and has no history of serious illness. Her only medication is a prenatal vitamin. Her temperature is 37.2°C (99°F) and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 16-week gestation. A quadruple screening test shows maternal serum AFP of 3 times the median and normal levels of serum β-hCG, estriol, and inhibin A. Which of the following is most likely to account for these findings? ---- <<Choices:>> A) Partial molar pregnancy B) Neural tube defect C) Trisomy 18 D) Trisomy 21 ---- <<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 39-year-old man presents to the emergency department complaining of a sharp pain that radiates along his right hemithorax, which worsens with deep inspiration. He says this started abruptly about 6 hours ago. He says that he has not noticed that anything that makes his pain better or worse. He also denies any other symptoms. He works as a long-haul truck driver, and he informs you that he recently returned to the east coast from a trip to Utah. His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type 2, and acute lymphoblastic leukemia from when he was a child. He currently smokes 2 packs of cigarettes/day, drinks a 6-pack of beer/day, and he denies any illicit drug use. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 98/min, and respiratory rate 23/min. His physical examination shows minimal bibasilar rales, but otherwise clear lungs on auscultation, normal heart sounds, and a benign abdominal physical examination. Which of the following is the most reasonable 1st step towards ruling out the diagnosis of pulmonary embolism in a low-risk patient? ---- <<Choices:>> A) ECG B) V/Q scan C) D-dimer D) CT pulmonary angiogram with IV contrast ---- <<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 presents to her primary care physician for evaluation of her right hand. Specifically, she says that she was gardening 8 hours prior to presentation when she sustained a laceration over her distal interphalangeal (DIP) joints. Since then, they have become red and swollen. She has also had pain in her proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints for several years and reports that this pain is worse in the morning but improves over the day. The cells that are present in this patient's DIP joints and PIP joints are analyzed and compared. Which of the following is most likely to be true about this patient's findings? ---- <<Choices:>> A) DIP has fewer neutrophils and more monocytes than PIP B) DIP has more neutrophils and fewer monocytes than PIP C) DIP has more neutrophils and more monocytes than PIP D) DIP and PIP have similar numbers of neutrophils and monocytes ---- <<Answer:>>
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B
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