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Answer the following medical question with one of the provided options:
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Q: A 50-year-old man presents with headache, chest discomfort, and blurred vision. His headache started 2 days ago and has not improved. He describes it as severe, throbbing, localized to the occipital part of the head and worse at the end of the day. He says he has associated nausea but denies any vomiting. Past medical history is significant for hypertension diagnosed 15 years ago, managed with beta-blockers until the patient self d/c’ed them a month ago. He has not seen a physician for the past 2 years. Family history is significant for hypertension and an ST-elevation myocardial infarction in his father and diabetes mellitus in his mother. Vitals signs are a blood pressure of 200/110 mm Hg, a pulse rate of 100/min and respiratory rate of 18/min Ophthalmoscopy reveals arteriolar nicking and papilledema. His ECG is normal. Laboratory findings are significant for a serum creatinine of 1.4 mg/dL and a blood urea nitrogen of 25 mg/dL. Urinalysis has 2+ protein. He is started on intravenous nitroprusside. Which of the following best explains the pathophysiology responsible for the neovascular changes present in this patient?? {'A': 'Smooth muscle hyperplasia and duplication of the basement membrane', 'B': 'Cholesterol deposition in the vascular lumen', 'C': 'Weakening of vessel wall following endothelial injury', 'D': 'Protein deposition in the vascular lumen', 'E': 'Transmural calcification of arterial walls'},
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A: Smooth muscle hyperplasia and duplication of the basement membrane
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Answer the following medical question with one of the provided options:
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Q:Forty minutes after undergoing nasal polypectomy for refractory rhinitis, a 48-year-old woman develops chest tightness and shortness of breath. The surgical course was uncomplicated and the patient was successfully extubated. She received ketorolac for postoperative pain. She has a history of asthma, hypertension, and aspirin allergy. Her daily medications include metoprolol and lisinopril. Examination shows a flushed face. Chest auscultation reveals wheezes and decreased breath sounds in both lung fields. An ECG shows no abnormalities. Which of the following is the most likely underlying cause of this patient's symptoms?? {'A': 'Type 1 hypersensitivity reaction', 'B': 'Prinzmetal angina', 'C': 'Pseudoallergic reaction', 'D': 'Excessive beta-adrenergic blockade', 'E': 'Bradykinin-induced bronchial irritation'},
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C: Pseudoallergic reaction
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Answer the following medical question with one of the provided options:
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Q:A 51-year-old man presents to his physician’s office with a persistent fever that started a week ago. He says that his temperature ranges between 37.8–39.1°C (100–102.5°F). He has also had a persistent cough productive of foul-smelling sputum. There is no significant medical history to report, but he does mention that he has been suffering from dental caries for the last month. He has been meaning to see his dentist but has been too busy to do so. His blood pressure is 120/70 mm Hg, the respirations are 18/min, and the temperature is 38.5°C (101.3°F). His oxygen saturation is 90% on room air. On examination, he has decreased breath sounds in his right lung field with the presence of soft inspiratory crackles. He is sent to the laboratory for sputum analysis and chest imaging. Based on his history and physical examination, which of the following would be the next best step in the management of this patient?? {'A': 'Surgical drainage', 'B': 'Metronidazole', 'C': 'Bronchoscopy', 'D': 'Clindamycin', 'E': 'Hospital admission'},
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D: Clindamycin
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Answer the following medical question with one of the provided options:
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Q:An 11-year-old boy is brought to the emergency department because he was found to have severe abdominal pain and vomiting in school. On presentation, he is found to be lethargic and difficult to arouse. His parents noticed that he was eating and drinking more over the last month; however, they attributed the changes to entering a growth spurt. Physical exam reveals deep and rapid breathing as well as an fruity odor on his breath. Which of the following sets of labs would most likely be seen in this patient?? {'A': 'A', 'B': 'B', 'C': 'C', 'D': 'D', 'E': 'E'},
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E: E
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Answer the following medical question with one of the provided options:
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Q:A 55-year-old man comes to the physician because of a 6-month history of cough, breathlessness, and fatigue. He has also had an 8-kg (17.6-lb) weight loss and night sweats during this time. He appears pale. His vital signs are within normal limits. Physical examination shows hepatosplenomegaly. His leukocyte count is 78,000/mm3. A peripheral blood smear shows > 80% neutrophils with band forms and immature and mature neutrophil precursors. A bone marrow biopsy shows hyperplasia with proliferation of all myeloid elements, and an increased leukocyte alkaline phosphatase activity. An x-ray of the chest shows an 8-mm nodule adjacent to the right lung hilum. Which of the following is the most likely cause of this patient's laboratory findings?? {'A': 'Acute myeloid leukemia', 'B': 'Acute lymphoblastic leukemia', 'C': 'Chronic myeloid leukemia', 'D': 'Leukemoid reaction', 'E': 'Tuberculosis\n"'},
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D: Leukemoid reaction
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Answer the following medical question with one of the provided options:
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Q:A 46-year-old woman comes to the clinic complaining of right eye irritation. The eye is itchy and red. Discomfort has been relatively constant for the last 6 months, and nothing makes it better or worse. Past medical history is significant for hypertension, hyperlipidemia, and aggressive tooth decay, requiring several root canals and the removal and replacement of several teeth. She takes chlorthalidone, fluvastatin, and daily ibuprofen for tooth pain. She has smoked a pack of cigarettes daily since the age of 20 and drinks alcohol on the weekends. She does not use illicit drugs. She cannot provide any family history as she was adopted. Her temperature is 36.7°C (98°F), blood pressure is 135/65 mm Hg, pulse is 82/min, respiratory rate is 15/min, and BMI is 27 kg/m2. A thorough eye exam is performed and shows no foreign objects. Both eyes appear erythematous and infected. Schirmer test is abnormal. Laboratory test Complete blood count: Hemoglobin 9.5 g/dL Leukocytes 12,500/mm3 Platelets 155,000/mm3 ESR 60 mm/hr Antinuclear antibody Positive What is the best next step in the management of this patient?? {'A': 'Artificial tears', 'B': 'Fundoscopy', 'C': 'Erythromycin ointment', 'D': 'Retinoscopy', 'E': 'Homatropine eye drops'},
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A: Artificial tears
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Answer the following medical question with one of the provided options:
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Q:A 20-year-old man presents to your office with dyspnea, reporting nocturnal cough. You note expiratory wheezing on auscultation. Chest x-ray reveals increased anteroposterior diameter. Past medical history is significant for multiple episodes of "bronchitis" as a child. Which of the following drugs would be most effective for long-term treatment of this patient?? {'A': 'Albuterol', 'B': 'Fluticasone', 'C': 'Theophylline', 'D': 'Ipratroprium', 'E': 'Zileuton'},
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B: Fluticasone
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Answer the following medical question with one of the provided options:
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Q:A 75-year-old woman presents complaining of severe shortness of breath and peripheral edema. Her family reports that she has gained a significant amount of weight within the past week. Despite considerable efforts in the emergency department and ICU, she dies from sudden cardiac death overnight. The family requests an autopsy to determine her cause of death. Amongst other studies, a biopsy of her liver is shown. What was the most likely cause of the liver changes shown?? {'A': 'Budd-Chiari syndrome', 'B': 'Congestive heart failure', 'C': 'Hepatic metastasis', 'D': 'Common bile duct obstruction', 'E': 'Amebic liver abscess'},
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B: Congestive heart failure
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Answer the following medical question with one of the provided options:
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Q:A 13-year-old girl is brought to the physician because of an itchy rash on her knee and elbow creases. She has had this rash since early childhood. Physical examination of the affected skin shows crusty erythematous papules with skin thickening. She is prescribed topical pimecrolimus. The beneficial effect of this drug is best explained by inhibition of which of the following processes?? {'A': 'Reduction of ribonucleotides', 'B': 'Oxidation of dihydroorotic acid', 'C': 'Oxidation of inosine-5-monophosphate', 'D': 'Synthesis of tetrahydrofolic acid', 'E': 'Dephosphorylation of serine'},
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E: Dephosphorylation of serine
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Answer the following medical question with one of the provided options:
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Q:A 46-year-old man comes to the physician for a follow-up examination. Two weeks ago, he underwent laparoscopic herniorrhaphy for an indirect inguinal hernia. During the procedure, a black liver was noted. He has a history of intermittent scleral icterus that resolved without treatment. Serum studies show: Aspartate aminotransferase 30 IU/L Alanine aminotransferase 35 IU/L Alkaline phosphatase 47 mg/dL Total bilirubin 1.7 mg/dL Direct bilirubin 1.1 mg/dL Which of the following is the most likely diagnosis?"? {'A': 'Type II Crigler-Najjar syndrome', 'B': 'Dubin-Johnson syndrome', 'C': 'Rotor syndrome', 'D': 'Gilbert syndrome', 'E': 'Type I Crigler-Najjar syndrome'},
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B: Dubin-Johnson syndrome
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Answer the following medical question with one of the provided options:
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Q:A 40-year-old woman comes to the physician because of a 6-day history of painless blisters on her hands, forearms, and face. Some of the blisters have popped and released a clear fluid. She is otherwise healthy. She had been working the night shift as a security guard for the past few years and switched to the day shift 2 weeks ago. She started wearing a new metal wristwatch last week. Her mother had a similar rash in the past. Her only medication is an estrogen-based oral contraceptive. She drinks 2 beers every night and occasionally more on the weekends. She used intravenous heroin in the past but stopped 20 years ago. Vital signs are within normal limits. Examination shows bullae and oozing erosions in different stages of healing on her arms, dorsal hands, ears, and face. Oral examination shows no abnormalities. There are some atrophic white scars and patches of hyperpigmented skin on the arms and face. Further evaluation of this patient is most likely to show which of the following findings?? {'A': 'Elevated anti-Smith antibodies', 'B': 'Elevated anti-varicella zoster virus antibodies', 'C': 'Elevated anti-transglutaminase antibodies', 'D': 'Positive skin patch test', 'E': 'Increased urinary uroporphyrin'},
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E: Increased urinary uroporphyrin
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Answer the following medical question with one of the provided options:
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Q:A 2-month-old boy is brought to the emergency room by his mother who reports he has appeared lethargic for the past 3 hours. She reports that she left the patient with a new nanny this morning, and he was behaving normally. When she got home in the afternoon, the patient seemed lethargic and would not breastfeed as usual. At birth, the child had an Apgar score of 8/9 and weighed 2.8 kg (6.1 lb). Growth has been in the 90th percentile, and the patient has been meeting all developmental milestones. There is no significant past medical history, and vaccinations are up-to-date. On physical examination, the patient does not seem arousable. Ophthalmologic examination shows retinal hemorrhages. Which of the following findings would most likely be expected on a noncontrast CT scan of the head?? {'A': 'Crescent-shaped hematoma', 'B': 'Lens-shaped hematoma', 'C': 'Blood in the basal cisterns', 'D': 'Cortical atrophy', 'E': 'Multiple cortical and subcortical infarcts'},
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A: Crescent-shaped hematoma
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Answer the following medical question with one of the provided options:
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Q:A 42-year-old man comes to his primary care physician complaining of abdominal pain. He describes intermittent, burning, epigastric pain over the past 4 months. He reports that the pain worsens following meals. He had an upper gastrointestinal endoscopy done 2 months ago that showed a gastric ulcer without evidence of malignancy. The patient was prescribed pantoprazole with minimal improvement in symptoms. He denies nausea, vomiting, diarrhea, or melena. The patient has no other medical problems. He had a total knee replacement 3 years ago following a motor vehicle accident for which he took naproxen for 2 months for pain management. He has smoked 1 pack per day since the age 22 and drinks 1-2 beers several nights a week with dinner. He works as a truck driver, and his diet consists of mostly of fast food. His family history is notable for hypertension in his paternal grandfather and coronary artery disease in his mother. On physical examination, the abdomen is soft, nondistended, and mildly tender in the mid-epigastric region. A stool test is positive for Helicobacter pylori antigen. In addition to antibiotic therapy, which of the following is the most likely to decrease the recurrence of the patient’s symptoms?? {'A': 'Celecoxib', 'B': 'Increase milk consumption', 'C': 'Low-fat diet', 'D': 'Octreotide', 'E': 'Smoking cessation'},
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E: Smoking cessation
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Answer the following medical question with one of the provided options:
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Q:An newborn infant comes to the attention of the neonatal care unit because he started having heavy and rapid breathing. In addition, he was found to be very irritable with pale skin and profuse sweating. Finally, he was found to have cold feet with diminished lower extremity pulses. Cardiac auscultation reveals a harsh systolic murmur along the left sternal border. Notably, the patient is not observed to have cyanosis. Which of the following treatments would most likely be effective for this patient's condition?? {'A': 'Leukotriene E4', 'B': 'Prostaglandin E1', 'C': 'Prostaglandin E2', 'D': 'Prostaglandin I2', 'E': 'Thromboxane A2'},
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B: Prostaglandin E1
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Answer the following medical question with one of the provided options:
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Q:A 50-year-old man with a history of stage 4 kidney disease was admitted to the hospital for an elective hemicolectomy. His past medical history is significant for severe diverticulitis. After the procedure he becomes septic and was placed on broad spectrum antibiotics. On morning rounds, he appear weak and complains of fatigue and nausea. His words are soft and he has difficulty answering questions. His temperature is 38.9°C (102.1°C), heart rate is 110/min, respiratory rate is 15/min, blood pressure 90/65 mm Hg, and saturation is 89% on room air. On physical exam, his mental status appears altered. He has a bruise on his left arm that spontaneously appeared overnight. His cardiac exam is positive for a weak friction rub. Blood specimens are collected and sent for evaluation. An ECG is performed (see image). What therapy will this patient most likely receive next?? {'A': 'Perform a STAT pericardiocentesis', 'B': 'Treat the patient with cyclophosphamide and prednisone', 'C': 'Send the patient for hemodialysis', 'D': 'Prepare the patient for renal transplant', 'E': 'Treat the patient with aspirin'},
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C: Send the patient for hemodialysis
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Answer the following medical question with one of the provided options:
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Q:A 56-year-old man comes to the physician for increasing shortness of breath and retrosternal chest pain on exertion. He has smoked 2 packs of cigarettes daily for 35 years. His blood pressure is 145/90 mm Hg. Cardiac examination is shown. Which of the following is the most likely cause of this patient's auscultation findings?? {'A': 'Left ventricular failure', 'B': 'Aortic valve sclerosis', 'C': 'Ventricular septal rupture', 'D': 'Right ventricular hypertrophy', 'E': 'Mitral valve stenosis'},
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A: Left ventricular failure
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Answer the following medical question with one of the provided options:
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Q:A 59-year-old man presents with fatigue and tingling in both feet and hands. Past medical history is significant for type 2 diabetes mellitus diagnosed 27 years ago, for which he takes metformin and gliclazide. He denies any smoking, alcohol, or illicit drug use. Physical examination is unremarkable. Laboratory results reveal the following: Hemoglobin 10.4 g/dL Hematocrit 31% Mean corpuscular volume 110 μm3 Corrected reticulocyte index low Leukocyte count 7,500 /mm3 Platelet count 250,000 /mm3 A peripheral blood smear is shown in the exhibit (see image). Which of the following best describes the underlying cause of this patient’s anemia?? {'A': 'Impaired DNA synthesis of red cells', 'B': 'Defect in heme synthesis', 'C': 'Defect in globin chain synthesis', 'D': 'Premature destruction of red cells', 'E': 'Myelodysplastic syndrome'},
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A: Impaired DNA synthesis of red cells
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Answer the following medical question with one of the provided options:
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Q:A 19-year-old man presents to his primary care physician for evaluation before going off to college. Specifically, he wants to know how to stay healthy while living outside his home. Since childhood he has suffered severe sunburns even when he goes outside for a small period of time. He has also developed many freckles and rough-surfaced growths starting at the same age. Finally, his eyes are very sensitive and become irritated, bloodshot, and painful after being outside. A defect in a protein with which of the following functions is most likely responsible for this patient's symptoms?? {'A': 'Distinguishing methylated from unmethylated strands', 'B': 'Endonucleolytic removal of bases from backbone', 'C': 'Recognition of chemically dimerized bases', 'D': 'Recognition of mismatched bases', 'E': 'Sister chromatid binding and recombination'},
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C: Recognition of chemically dimerized bases
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Answer the following medical question with one of the provided options:
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Q:An 11-year-old boy presents to your clinic after 4 months of pain and swelling in his thigh. His mother states that at first she thought his condition was due to roughhousing, but it hasn’t gone away and now she’s concerned. You perform an X-ray that shows an ‘onion skin’ appearance on the diaphysis of the femur. You are concerned about a malignancy, so you perform a PET scan that reveals lung nodules. Which of the following is most associated with this disease?? {'A': 'Nonsense mutation to DMD gene', 'B': 'Defective mitochondrial DNA', 'C': 't(11;22) translocation', 'D': 't(9;22) translocation', 'E': 'Rb loss of function mutation'},
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C: t(11;22) translocation
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Answer the following medical question with one of the provided options:
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Q:A 53-year-old woman presents to her physician for evaluation of sudden onset respiratory distress for the past few hours. The past medical history includes a myocardial infarction 2 years ago. The vital signs include a blood pressure 70/40 mm Hg, pulse 92/min, respiratory rate 28/min, and SpO2 92% on room air. The physical examination reveals bilateral basal crepitations on auscultation. The echocardiogram reveals an ejection fraction of 34%. She is admitted to the medical floor and started on furosemide. The urine output in 24 hours is 400 mL. The blood urea nitrogen is 45 mg/dL and the serum creatinine is 1.85 mg/dL. The fractional excretion of sodium is 0.89 %. Urinalysis revealed muddy brown granular casts. Which of the following is the most likely cause of the abnormal urinalysis?? {'A': 'Acute glomerulonephritis', 'B': 'Chronic kidney disease', 'C': 'Acute pyelonephritis', 'D': 'Acute interstitial nephritis', 'E': 'Acute tubular necrosis'},
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E: Acute tubular necrosis
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Answer the following medical question with one of the provided options:
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Q:A 34-year-old man presents to the neurology clinic for an appointment after having been referred by his family physician. Four months earlier, he presented with worsening upper limb weakness. His primary complaint at that time was that he was unable to play badminton because of increasing difficulty in moving his shoulders and arms. The weakness later progressed, and he now has spontaneous twitching of his leg and thigh muscles throughout the day. He also feels increasingly fatigued. On physical examination, there is significant atrophy of his arm and thigh muscles. Cranial nerves testing is unremarkable. The pupillary light and accommodation reflexes are both normal. Swallowing, speech, and eye movements are all normal. His cousin had similar symptoms at the age of 19 years old. Which of the following is most likely to also be seen in this patient?? {'A': 'Paresthesia', 'B': 'Bowel incontinence', 'C': 'Spastic paralysis', 'D': 'Cape-like sensory loss', 'E': 'Positive Romberg sign'},
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C: Spastic paralysis
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Answer the following medical question with one of the provided options:
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Q:A 27-year-old woman with cystic fibrosis comes to the physician for a follow-up examination. She has been hospitalized frequently for pneumonia and nephrolithiasis and is on chronic antibiotic therapy for recurrent sinusitis. The patient and her husband would like to have a child but have been unable to conceive. She feels that she can never achieve a full and happy life due to her disease and says that she is “totally frustrated” with the barriers of her illness. Although her family is supportive, she doesn't want to feel like a burden and tries to shield them from her struggles. Which of the following is the most appropriate statement by the physician?? {'A': '"""I think it\'s really important that you talk to your family more about this. I\'m sure they can help you out."""', 'B': '"""You should educate yourself about your disease or condition using credible, current sources. Knowledge can help dispel fear and anxiety."""', 'C': '"""I understand that living with cystic fibrosis is not easy. You are not alone in this. I would like to recommend a support group."""', 'D': '"""I understand your frustration with your situation. I would like to refer you to a therapist."""', 'E': '"""I see that you are frustrated, but this illness has its ups and downs. I am sure you will feel much better soon."""'},
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C: """I understand that living with cystic fibrosis is not easy. You are not alone in this. I would like to recommend a support group."""
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Answer the following medical question with one of the provided options:
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Q:A 34-year-old male visits the clinic with complaints of intermittent diarrhea over the past 6 months. He has lost 6.8 kg (15 lb) over that time period. His frequent bowel movements are affecting his social life and he would like definitive treatment. Past medical history is significant for chronic type 2 diabetes that is well controlled with insulin. No other family member has a similar condition. He does not smoke tobacco and drinks alcohol only on weekends. Today, his vitals are within normal limits. On physical exam, he appears gaunt and anxious. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Additionally, the patient has a red-purple rash on his lower abdomen, groin, and the dorsum of both hands. The rash consists of pruritic annular lesions. He is referred to a dermatologist for core biopsy which is consistent with necrolytic migratory erythema. Further workup reveals a large hormone secreting mass in the tail of his pancreas. Which of the following is the action of the hormone that is in excess in this patient?? {'A': 'Activation of glycogen synthase', 'B': 'Inhibition of acetone production', 'C': 'Inhibition of gluconeogenesis', 'D': 'Inhibition of insulin secretion', 'E': 'Stimulation of lipolysis'},
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E: Stimulation of lipolysis
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Answer the following medical question with one of the provided options:
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Q:A 15-year-old girl is brought to the clinic by her mother for an annual well-exam. She is relatively healthy with an unremarkable birth history. She reports no specific concerns except for the fact that her friends “already got their periods and I still haven’t gotten mine.” Her mom reports that she also had her menarche late and told her not to worry. When alone, the patient denies any pain, fevers, weight changes, vaginal discharge, or psychosocial stressors. Physical examination demonstrates a healthy female with a Tanner 4 stage of development of breast, genitalia, and pubic hair. What findings would you expect in this patient?? {'A': 'Coarse hair across pubis and medial thigh', 'B': 'Flat chest with raised nipples', 'C': 'Formation of breast bud', 'D': 'Formation of breast mound', 'E': 'Raised areola'},
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E: Raised areola
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Answer the following medical question with one of the provided options:
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Q:A 55-year-old man with long-standing diabetes presents with a fragility fracture. He has chronic renal failure secondary to his diabetes. His serum parathyroid hormone concentration is elevated. You measure his serum concentration of 25(OH)-vitamin D and find it to be normal, but his concentration of 1,25(OH)-vitamin D is decreased. Which of the following represents a correct pairing of his clinical condition and serum calcium level?? {'A': 'Primary hyperparathyroidism with elevated serum calcium', 'B': 'Primary hyperparathyroidism with low serum calcium', 'C': 'Secondary hyperparathyroidism with elevated serum calcium', 'D': 'Secondary hyperparathyroidism with low serum calcium', 'E': 'Tertiary hyperparathyroidism with low serum calcium'},
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D: Secondary hyperparathyroidism with low serum calcium
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Answer the following medical question with one of the provided options:
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Q:A 47-year-old man with bipolar I disorder and hypertension comes to the physician because of a 2-week history of increased thirst, urinary frequency, and sleep disturbance. He says that he now drinks up to 30 cups of water daily. He has smoked 2 packs of cigarettes daily for the past 20 years. Examination shows decreased skin turgor. Serum studies show a sodium concentration of 149 mEq/L, a potassium concentration of 4.1 mEq/L, and an elevated antidiuretic hormone concentration. His urine osmolality is 121 mOsm/kg H2O. Which of the following is the most likely explanation for these findings?? {'A': 'Polydipsia caused by acute psychosis', 'B': 'Adverse effect of a medication', 'C': 'Tumor of the pituitary gland', 'D': 'Paraneoplastic production of a hormone', 'E': 'Tumor in the adrenal cortex'},
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B: Adverse effect of a medication
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Answer the following medical question with one of the provided options:
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Q:A 23-year-old man comes to his primary care provider after having severe abdominal cramping and diarrhea beginning the previous night. He denies any fevers or vomiting. Of note, he reports that he works in a nursing home and that several residents of the nursing home exhibited similar symptoms this morning. On exam, his temperature is 99.7°F (37.6°C), blood pressure is 116/80 mmHg, pulse is 88/min, and respirations are 13/min. His stool is cultured on blood agar and it is notable for a double zone of hemolysis. Which of the following organisms is the most likely cause?? {'A': 'Clostridium difficile', 'B': 'Clostridium perfringens', 'C': 'Enterococcus faecalis', 'D': 'Listeria monocytogenes', 'E': 'Streptococcus pneumoniae'},
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B: Clostridium perfringens
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Answer the following medical question with one of the provided options:
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Q:A 79-year-old man with a history of prostate cancer is brought to the emergency department because of lower abdominal pain for 1 hour. He has not urinated for 24 hours. Abdominal examination shows a palpable bladder that is tender to palpation. A pelvic ultrasound performed by the emergency department resident confirms the diagnosis of acute urinary retention. An attempt to perform transurethral catheterization is unsuccessful. A urology consultation is ordered and the urologist plans to attempt suprapubic catheterization. As the urologist is called to see a different emergency patient, she asks the emergency department resident to obtain informed consent for the procedure. The resident recalls a lecture about the different modes of catheterization, but he has never seen or performed a suprapubic catheterization himself. Which of the following statements by the emergency department resident is the most appropriate?? {'A': '“I will make sure the patient reads and signs the informed consent form.”', 'B': "“I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency.”", 'C': '“Suprapubic catheterization is not the treatment of choice for this patient.”', 'D': '“I would prefer that you obtain informed consent when you become available again.”', 'E': '“I will ask the patient to waive informed consent because this is an urgent procedure.”'},
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D: “I would prefer that you obtain informed consent when you become available again.”
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Answer the following medical question with one of the provided options:
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Q:A 45-year-old man with a body mass index of 45 kg/m^2 presents to his primary care doctor with right hip pain. He asserts that the pain is instigated by walking up and down stairs around a construction site which he oversees. On physical exam, his hips are symmetric and equal with no tenderness to palpation bilaterally. His left lower extremity appears grossly normal with full range of motion. His right knee appears symmetric, but the patient whimpers when the anteromedial part of the tibial plateau is pressed. No other parts of his knee are tender. No tenderness is elicited with extension, flexion, varus, and valgus movements of the knee. McMurray's test is negative with both internal and external rotation of the right leg. What is the most likely diagnosis?? {'A': 'Lateral meniscus tear', 'B': 'Medial meniscus tear', 'C': 'Patellar tendinitis', 'D': 'Pes anserine bursitis', 'E': 'Prepatellar bursitis'},
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D: Pes anserine bursitis
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Answer the following medical question with one of the provided options:
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Q:A 12-year-old girl with a recently diagnosed seizure disorder is brought to the physician by her mother for genetic counseling. She has difficulties in school due to a learning disability. Medications include carbamazepine. She is at the 95th percentile for height. Genetic analysis shows a 47, XXX karyotype. An error in which of the following stages of cell division is most likely responsible for this genetic abnormality?? {'A': 'Maternal meiosis, metaphase II', 'B': 'Maternal meiosis, anaphase II', 'C': 'Maternal meiosis, telophase II', 'D': 'Paternal meiosis, metaphase II', 'E': 'Paternal meiosis, anaphase I'},
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B: Maternal meiosis, anaphase II
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Answer the following medical question with one of the provided options:
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Q:A 27-year-old woman comes to the physician for a 1-week-history of painful urination and urinary frequency. She has no history of serious illness and takes no medications. She is sexually active with her boyfriend. Her temperature is 36.7°C (98.1°F). There is no costovertebral angle tenderness. Urine dipstick shows leukocyte esterase. A Gram stain does not show any organisms. Which of the following is the most likely causal pathogen?? {'A': 'Neisseria gonorrhoeae', 'B': 'Escherichia coli', 'C': 'Gardnerella vaginalis', 'D': 'Chlamydia trachomatis', 'E': 'Trichomonas vaginalis'},
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D: Chlamydia trachomatis
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Answer the following medical question with one of the provided options:
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Q:A 48-year-old man is brought to the emergency department 1 hour after the sudden onset of chest pain and shortness of breath. He describes the pain as severe and occasionally migrating to his left arm and back. He has hypertension treated with hydrochlorothiazide and lisinopril. He has smoked one pack of cigarettes daily for 30 years. On exam, he is in severe distress. His pulse is 105/min, respirations are 22/min, and blood pressure is 170/90 mm Hg. An ECG shows sinus tachycardia and left ventricular hypertrophy. A CT scan of the chest is shown. Which of the following is the most appropriate next step in management?? {'A': 'Begin heparin therapy', 'B': 'Surgical intervention only', 'C': 'Administer labetalol', 'D': 'Administer tissue plasminogen activator', 'E': 'Administer aspirin'},
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C: Administer labetalol
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Answer the following medical question with one of the provided options:
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Q:A 31-year-old G2P1001 presents to the labor floor for external cephalic version (ECV) due to breech presentation at 37 weeks gestation. Her pregnancy has been complicated by an episode of pyelonephritis at 14 weeks gestation, treated with intravenous ceftriaxone. The patient has not had urinary symptoms since that time. Otherwise, her prenatal care has been routine and she tested Rh-negative with negative antibodies at her first prenatal visit. She has a history of one prior spontaneous vaginal delivery without complications. She also has a medical history of anemia. Current medications include nitrofurantoin for urinary tract infection suppression and iron supplementation. The patient’s temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min. Physical exam is notable for a fundal height of 37 centimeters and mild pitting edema in both lower extremities. Cardiopulmonary exams are unremarkable. Bedside ultrasound confirms that the fetus is still in breech presentation. Which of the following should be performed in this patient as a result of her upcoming external cephalic version?? {'A': 'Complete blood count', 'B': 'Urinalysis', 'C': 'Fibrinogen level', 'D': 'Urine protein to creatinine ratio', 'E': 'Rhogam administration'},
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E: Rhogam administration
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Answer the following medical question with one of the provided options:
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Q:A 24-year-old college student consumed a container of canned vegetables for dinner. Fourteen hours later, he presents to the E.R. complaining of difficulty swallowing and double-vision. The bacterium leading to these symptoms is:? {'A': 'An obligate aerobe', 'B': 'Gram-negative', 'C': 'Rod-shaped', 'D': 'Non-spore forming', 'E': 'Cocci-shaped'},
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C: Rod-shaped
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Q:A 9-year-old boy is brought to the emergency department by his mother. She says that he started having “a cold” yesterday, with cough and runny nose. This morning, he was complaining of discomfort with urination. His mother became extremely concerned when he passed bright-red urine with an apparent blood clot. The boy is otherwise healthy. Which of the following is the most likely underlying cause?? {'A': 'Adenovirus infection', 'B': 'BK virus infection', 'C': 'CMV virus infection', 'D': 'E. coli infection', 'E': 'Toxin exposure'},
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A: Adenovirus infection
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Answer the following medical question with one of the provided options:
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Q:A 33-year-old female comes to her primary care physician with complaints of fatigue and nausea. She has also noticed that her skin tone is darker than it used to be. On exam, the physician notes that the woman appears to be jaundiced and obtains liver enzymes which demonstrate an elevated AST and ALT. Further testing subsequently confirms the diagnosis of hepatitis B (HBV). The woman is extremely concerned about transmitting this disease to her loved ones and ask how HBV is transmitted. By which of the following routes can HBV be spread? (I) blood, (II) sexual contact, (III) maternal-fetal, and/or (IV) breast milk?? {'A': 'I only', 'B': 'I, II, III, IV', 'C': 'I, III, IV', 'D': 'II, III', 'E': 'I, II, III'},
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B: I, II, III, IV
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Q:A 46-year-old man comes to the physician because of a 4-month history of progressively worsening fatigue and loss of appetite. Five years ago, he received a kidney transplant from a living family member. Current medications include sirolimus and mycophenolate. His blood pressure is 150/95 mm Hg. Laboratory studies show normocytic, normochromic anemia and a serum creatinine concentration of 3.1 mg/dL; his vital signs and laboratory studies were normal 6 months ago. Which of the following is the most likely underlying mechanism of this patient’s increase in creatinine concentration?? {'A': 'CD8+ T cell-mediated parenchymal cell damage', 'B': 'Donor T cell-mediated epithelial cell damage', 'C': 'Donor endothelial cell damage by preformed host antibodies', 'D': 'CD4+ T cell-mediated intimal smooth muscle proliferation', 'E': 'Drug-induced tubular vacuolization'},
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D: CD4+ T cell-mediated intimal smooth muscle proliferation
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Q:A 27-year-old woman visits a psychiatrist expressing her feelings of sadness which are present on most days of the week. She says that she has been feeling this way for about 2 to 3 years. During her first pregnancy 3 years ago, the fetus died in utero, and the pregnancy was terminated at 21 weeks. Ever since then, she hasn’t been able to sleep well at night and has difficulty concentrating on her tasks most of the time. However, for the past month, she has found it more difficult to cope. She says she has no will to have another child as she still feels guilty and responsible for the previous pregnancy. Over the past few days, she has completely lost her appetite and only eats once or twice a day. She doesn’t recall a single day in the last 3 years where she has not felt this way. The patient denies any past or current smoking, alcohol, or recreational drug use. Which of the following is the most likely diagnosis in this patient?? {'A': 'Persistent depressive disorder', 'B': 'Cyclothymia', 'C': 'Major depressive disorder', 'D': 'Bipolar disorder', 'E': 'Schizoaffective disorder'},
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A: Persistent depressive disorder
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Q:A 25-day-old newborn is brought to the pediatrician for lethargy, poor muscle tone, and feeding difficulty with occasional regurgitation that recently turned into projectile vomiting. The child was born via vaginal delivery without complications. On examination, the vital signs include: pulse 130/min, respiratory rate 30/min, blood pressure 96/60 mm Hg, and temperature 36.5°C (97.7°F). The physical examination shows a broad nasal bridge, oral thrush, hepatosplenomegaly, and generalized hypotonia. Further tests of blood and urine samples help the pediatrician to diagnose the child with an enzyme deficiency. More extensive laboratory testing reveals normal levels of citrulline and hypoglycemia. There are also elevated levels of ketone bodies, glycine, and methylmalonic acid. Which of the following is the product of the reaction catalyzed by the deficient enzyme in this patient?? {'A': 'Pyruvate', 'B': 'Succinyl-CoA', 'C': 'Methylmalonyl-CoA', 'D': 'Acetyl-CoA', 'E': 'Enoyl-CoA'},
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B: Succinyl-CoA
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Q:A 48-year-old woman comes to the emergency department because of increasingly severe right upper abdominal pain, fever, and nonbloody vomiting for 5 hours. The pain is dull and intermittent and radiates to her right shoulder. During the past 3 months, she had recurring abdominal discomfort after meals. She underwent an appendectomy at the age of 13 years. The patient has hypertension, type 2 diabetes mellitus, and chronic back pain. She takes bisoprolol, metformin, and ibuprofen daily. She is 171 cm (5 ft 6 in) tall and weighs 99 kg (218 lb); BMI is 35 kg/m2. She appears uncomfortable and is clutching her abdomen. Her temperature is 38.5°C (101.3°F), pulse is 108/min, and blood pressure is 150/82 mm Hg. Abdominal examination shows right upper quadrant abdominal tenderness and guarding. Upon deep palpation of the right upper quadrant, the patient pauses during inspiration. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 10,900/mm3 Platelet count 236,000/mm3 Mean corpuscular volume 89/μm3 Serum Urea nitrogen 28 mg/dL Glucose 89 mg/dL Creatinine 0.7 mg/dL Bilirubin Total 1.6 mg/dL Direct 1.1 mg/dL Alkaline phosphatase 79 U/L Alanine aminotransferase (ALT, GPT) 28 U/L Aspartate aminotransferase (AST, GOT) 32 U/L An x-ray of the abdomen shows no abnormalities. Further evaluation of the patient is most likely to reveal which of the following?"? {'A': 'History of multiple past pregnancies', 'B': 'History of recurrent sexually transmitted infections', 'C': 'Frequent, high-pitched bowel sounds on auscultation', 'D': 'History of intravenous drug abuse', 'E': 'Urine culture growing gram-negative rods'},
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A: History of multiple past pregnancies
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Q:A 2-day-old boy is examined on day of discharge from the newborn nursery. He was born at 39 weeks by vaginal delivery to a primigravid mother. The pregnancy and delivery were uncomplicated, and the baby has been stooling, urinating, and feeding normally. Both the patient’s mother and father have no known past medical history and are found to have normal hemoglobin electrophoresis results. Compared to adult hemoglobin, the infant’s predominant hemoglobin is most likely to exhibit which of the following properties?? {'A': 'More likely to cause red blood cell sickling', 'B': 'Lower affinity for binding oxygen', 'C': 'More likely to form hexagonal crystals', 'D': 'Decreased affinity for 2,3-bisphosphoglycerate', 'E': 'Increased affinity for 2,3-bisphosphoglycerate'},
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D: Decreased affinity for 2,3-bisphosphoglycerate
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Q:An investigator is comparing DNA replication in prokaryotes and eukaryotes. He finds that the entire genome of E. coli (4 × 106 base pairs) is replicated in approximately 30 minutes. A mammalian genome (3 × 109 base pairs) is usually replicated within 3 hours. Which of the following characteristics of eukaryotic DNA replication is the most accurate explanation for this finding?? {'A': 'Absence of telomerase enzyme activity', 'B': 'Replication inhibition at checkpoint', 'C': 'Simultaneous replication at multiple origins', 'D': 'DNA compaction in chromatin', 'E': 'More efficient DNA polymerase activity'},
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C: Simultaneous replication at multiple origins
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Q:A 23-year-old woman presents to the emergency department after fainting at a baseball game. The patient was using the bathroom and upon standing up, felt a warm and tingling sensation followed by an episode of syncope that lasted for about 5 seconds. While the patient was unconscious, bystanders observed twitching and contractile motions of her upper extremities. When the patient awoke, she recalled falling and the events leading up to her fainting and was not confused. The patient has no other medical diagnoses. Her temperature is 97.7°F (36.5°C), blood pressure is 124/84 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for a healthy young woman. Cranial nerves II-XII are grossly intact, and cerebellar function and gait are unremarkable. She has normal strength of her upper and lower extremities. An ECG is notable for normal sinus rhythm with a normal axis and normal voltages. Which of the following is the best next step in management for this patient?? {'A': 'CT head', 'B': 'Discharge the patient with reassurance', 'C': 'Echocardiography', 'D': 'EEG', 'E': 'Serum toxicology'},
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B: Discharge the patient with reassurance
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Q:A 15-year-old girl is brought in by her parents to her pediatrician with concerns that their daughter still has not had her first menstrual cycle. The parents report that the patient has had no developmental issues in the past. She was born full term by vaginal delivery and has met all other milestones growing up. Based on chart review, the patient demonstrated breast bud development at 10 years of age. The patient is not self conscious of her appearance but is concerned that something may be wrong since she has not yet had her first period. The patient’s temperature is 97.9°F (36.6°C), blood pressure is 116/70 mmHg, pulse is 66/min, and respirations are 12/min. On exam, the patient appears her stated age and is of normal stature. She has Tanner 5 breast development but Tanner 2 pubic hair. On gynecologic exam, external genitalia appears normal, but the vagina ends in a blind pouch. Lab studies demonstrate that the patient has elevated levels of testosterone, estrogen, and luteinizing hormone. Which of the following is the most likely karyotype for this patient?? {'A': '45, XO', 'B': '46, XX', 'C': '46, XY', 'D': '47, XXY', 'E': '47, XYY'},
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C: 46, XY
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Q:A microbiologist is involved in research on the emergence of a novel virus, X, which caused a recent epidemic in his community. After studying the structure of the virus, he proposes a hypothesis: Virus X developed from viruses A and B. He suggests that viruses A and B could co-infect a single host cell. During the growth cycles of the viruses within the cells, a new virion particle is formed, which contains the genome of virus A; however, its coat contains components of the coats of both viruses A and B. This new virus is identical to virus X, which caused the epidemic. Which of the following phenomena is reflected in the hypothesis proposed by the microbiologist?? {'A': 'Genetic reassortment', 'B': 'Genetic recombination', 'C': 'Complementation', 'D': 'Phenotypic mixing', 'E': 'Antigenic shift'},
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D: Phenotypic mixing
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Q:A previously healthy 5-year-old boy is brought to the physician because of a 2-day history of itchy rash and swelling on his left lower leg. His mother says the boy complained of an insect bite while playing outdoors 3 days before the onset of the lesion. His immunizations are up-to-date. He is at the 50th percentile for height and the 85th percentile for weight. He has no known allergies. His temperature is 38.5°C (101.3°F), pulse is 120/min, and blood pressure is 95/60 mm Hg. The lower left leg is swollen and tender with erythema that has sharply defined borders. There is also a narrow red line with a raised border that extends from the lower leg to the groin. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of these findings?? {'A': 'Staphylococcus aureus infection', 'B': 'Sporothrix schenckii infection', 'C': 'Contact dermatitis', 'D': 'Vasculitis', 'E': 'Streptococcus pyogenes infection\n"'},
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E: Streptococcus pyogenes infection "
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Q:A 52-year-old man presents to the emergency room after a syncopal episode. The patient is awake, alert, and oriented; however, he becomes lightheaded whenever he tries to sit up. The medical history is significant for coronary artery disease and stable angina, which are controlled with simvastatin and isosorbide dinitrate, respectively. The blood pressure is 70/45 mm Hg and the heart rate is 110/min; all other vital signs are stable. IV fluids are started as he is taken for CT imaging of the head. En route to the imaging suite, the patient mentions that he took a new medication for erectile dysfunction just before he began to feel ill. What is the metabolic cause of this patient’s symptoms?? {'A': 'Increased PDE-5', 'B': 'Increased NO', 'C': 'Increased cGMP', 'D': 'Increased O2 consumption', 'E': 'Nitric oxide synthase inhibition'},
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C: Increased cGMP
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Q:A 32-year-old woman is admitted to the hospital after undergoing an open cholecystectomy under general anesthesia. Preoperatively, the patient was administered a single dose of intravenous ceftriaxone. Now, the anesthetic effects have worn off, and her pain is well managed. The patient has a prior medical history of hypertension which has been well-controlled by captopril for 2 years. Her vitals currently show: blood pressure 134/82 mm Hg, heart rate 84/min, and respiratory rate 16/min. Postoperative laboratory findings are significant for the following: Serum glucose (random) 174 mg/dL Serum electrolytes Sodium 142 mEq/L Potassium 3.9 mEq/L Chloride 101 mEq/L Serum creatinine 0.9 mg/dL Blood urea nitrogen 10 mg/dL Alanine aminotransferase (ALT) 150 U/L Aspartate aminotransferase (AST) 172 U/L Serum bilirubin (total) 0.9 mg/dL Preoperative labs were all within normal limits. Which of the following drugs is most likely responsible for this patient’s abnormal laboratory findings?? {'A': 'Captopril', 'B': 'Propofol', 'C': 'Nitrous oxide', 'D': 'Halothane', 'E': 'Ceftriaxone'},
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D: Halothane
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Q:A 2-month-old infant is brought to his pediatrician because of recurrent episodes of vomiting. Specifically, his parents say that he starts to vomit as soon as he is laid down after feeding. He was born at full term and had no complications in the perinatal period. Contrast radiograph reveals part of the stomach is within the thoracic cavity. Which of the following symptoms would most likely be experienced if this patient's condition presented in an adult?? {'A': 'Cholecystitis', 'B': 'Dyspnea', 'C': 'Pancreatitis', 'D': 'Reflux', 'E': 'Sleep apnea'},
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D: Reflux
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Q:A 27-year-old man is brought to the emergency department from a homeless shelter because of bizarre behavior. He avoids contact with others and has complained to the supervising staff that he thinks people are reading his mind. Three days ago, he unplugged every electrical appliance on his floor of the shelter because he believed they were being used to transmit messages about him to others. The patient has schizophrenia and has been prescribed risperidone but has been unable to comply with his medications because of his unstable living situation. He is disheveled and malodorous. His thought process is disorganized and he does not make eye contact. Which of the following is the most appropriate long-term pharmacotherapy?? {'A': 'Intravenous propranolol', 'B': 'Oral haloperidol', 'C': 'Intramuscular benztropine', 'D': 'Oral diazepam', 'E': 'Intramuscular risperidone'},
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E: Intramuscular risperidone
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Answer the following medical question with one of the provided options:
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Q:A 66-year-old woman presents to the emergency department complaining of palpitations. She says that she has been experiencing palpitations and lightheadedness for the past 6 months, but before this morning the episodes usually resolved on their own. The patient’s medical history is significant for a transient ischemia attack 2 months ago, hypertension, and diabetes. She takes aspirin, metformin, and lisinopril. She states her grandfather died of a stroke, and her mom has a "blood disorder." An electrocardiogram is obtained that shows an irregularly irregular rhythm with rapid ventricular response, consistent with atrial fibrillation. She is given intravenous metoprolol, which resolves her symptoms. In addition to starting a beta-blocker for long-term management, the patient meets criteria for anticoagulation. Both unfractionated heparin and warfarin are started. Five days later, the patient begins complaining of pain and swelling of her left lower extremity. A Doppler ultrasound reveals thrombosis in her right popliteal and tibial veins. A complete blood count is obtained that shows a decrease in platelet count from 245,000/mm^3 to 90,000/mm^3. Coagulation studies are shown below: Prothrombin time (PT): 15 seconds Partial thromboplastin time (PTT): 37 seconds Bleeding time: 14 minutes Which of the following is the most likely diagnosis?? {'A': 'Idiopathic thrombocytopenia purpura', 'B': 'Thrombotic thrombocytopenic purpura', 'C': 'Type I heparin-induced thrombocytopenia', 'D': 'Type II heparin-induced thrombocytopenia', 'E': 'Warfarin toxicity'},
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D: Type II heparin-induced thrombocytopenia
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Q:A 30-year-old man presents with dark urine and fatigue. The patient states that the symptoms started 2 days ago. Since yesterday, he also noticed that his eyes look yellow. The past medical history is significant for recent right ear pain diagnosed 3 days ago as acute otitis media, which he was prescribed trimethoprim-sulfamethoxazole. He currently does not take any other medications on a daily basis. The patient was adopted and has no knowledge of his family history. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/75 mm Hg, pulse 105/min, respiratory rate 15/min, and oxygen saturation 100% on room air. On physical exam, the patient is alert and cooperative. The cardiac exam is significant for an early systolic murmur that is best heard at the 2nd intercostal space, midclavicular line. There is scleral icterus present. The peripheral blood smear shows the presence of bite cells and Heinz bodies. Which of the following laboratory findings would most likely be present in this patient?? {'A': 'Increased serum haptoglobin', 'B': 'Decreased reticulocyte count', 'C': 'Decreased indirect bilirubin levels', 'D': 'Increased serum lactate dehydrogenase (LDH)', 'E': 'Decreased mean corpuscular volume'},
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D: Increased serum lactate dehydrogenase (LDH)
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Answer the following medical question with one of the provided options:
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Q:A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?? {'A': 'Diaphragm and renal arteries', 'B': 'Diaphragm and superior mesenteric artery', 'C': 'Renal arteries and common iliac arteries', 'D': 'Superior mesenteric artery and common iliac arteries', 'E': 'Superior mesenteric artery and renal arteries'},
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C: Renal arteries and common iliac arteries
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Q:A 17-year-old girl is brought to the emergency department 6 hours after she attempted suicide by consuming 16 tablets of acetaminophen (500 mg per tablet). At present, she does not have any complaints or symptoms. The patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Laboratory findings show a serum acetaminophen level that is predictive of ‘probable hepatic toxicity’ on the Rumack-Matthew nomogram. Treatment is started with a drug, which is a precursor of glutathione and is a specific antidote for acetaminophen poisoning. Which of the following is an additional beneficial mechanism of action of this drug in this patient?? {'A': 'Prevents gastrointestinal absorption of acetaminophen', 'B': 'Promotes glucuronidation of unmetabolized acetaminophen', 'C': 'Promotes fecal excretion of unabsorbed acetaminophen', 'D': 'Promotes microcirculatory blood flow', 'E': 'Promotes oxidation of N-acetyl-p-benzoquinoneimine (NAPQI)'},
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D: Promotes microcirculatory blood flow
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Answer the following medical question with one of the provided options:
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Q:A 70-year-old man comes to the physician because of a 2-month history of progressive shortness of breath and a dry cough. He has also noticed gradual development of facial discoloration. He has not had fevers. He has coronary artery disease, hypertension, and atrial fibrillation. He does not smoke or drink alcohol. He does not remember which medications he takes. His temperature is 37°C (98.6°F), pulse is 90/min, respirations are 18/min, and blood pressure is 150/85 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 95%. Examination shows blue-gray discoloration of the face and both hands. Diffuse inspiratory crackles are heard. Laboratory studies show: Prothrombin time 12 seconds (INR=1.0) Serum Na+ 142 mEq/L Cl- 105 mEq/L K+ 3.6 mEq/L HCO3- 25 mg/dL Urea Nitrogen 20 Creatinine 1.2 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 120 U/L Alanine aminotransferase (ALT, GPT) 110 U/L An x-ray of the chest shows reticular opacities around the lung periphery and particularly around the lung bases. The most likely cause of this patient's findings is an adverse effect to which of the following medications?"? {'A': 'Lisinopril', 'B': 'Procainamide', 'C': 'Warfarin', 'D': 'Metoprolol', 'E': 'Amiodarone'},
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E: Amiodarone
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Answer the following medical question with one of the provided options:
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Q:A 65-year-old man presents to the emergency department with vague, constant abdominal pain, and worsening shortness of breath for the past several hours. He has baseline shortness of breath and requires 2–3 pillows to sleep at night. He often wakes up because of shortness of breath. Past medical history includes congestive heart failure, diabetes, hypertension, and hyperlipidemia. He regularly takes lisinopril, metoprolol, atorvastatin, and metformin. His temperature is 37.0°C (98.6°F), respiratory rate 25/min, pulse 67/min, and blood pressure 98/82 mm Hg. On physical examination, he has bilateral crackles over both lung bases and a diffusely tender abdomen. His subjective complaint of abdominal pain is more severe than the observed tenderness on examination. Which of the following vessels is involved in the disease affecting this patient?? {'A': 'Meandering mesenteric artery', 'B': 'Left anterior descending', 'C': 'Right coronary artery', 'D': 'Celiac artery and superior mesenteric artery', 'E': 'Left colic artery'},
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A: Meandering mesenteric artery
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Answer the following medical question with one of the provided options:
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Q:A 28-year-old man presents to the emergency department with diffuse abdominal pain and nausea for the past 5 hours. The pain started with a dull ache but is now quite severe. He notes that he “just doesn’t feel like eating” and has not eaten anything for almost a day. Although the nausea is getting worse, the patient has not vomited. He notes no medical issues in the past and is not currently taking any medications. He admits to drinking alcohol (at least 2–3 bottles of beer per day after work and frequent binge-drinking weekends with friends). He says that he does not smoke or use illicit drugs. Vital signs include: pulse rate 120/min, respiratory rate 26/min, and blood pressure 100/70 mm Hg. On examination, the patient’s abdomen is diffusely tender. His breath smells like alcohol, with a fruity tinge to it. Bowel sounds are present. No other findings are noted. Fingerstick glucose is 76mg/dL. After the examination, the patient suddenly and spontaneously vomits. Which of the following is the underlying mechanism of the most likely diagnosis in this patient?? {'A': 'Increased acetyl CoA levels', 'B': 'Inadequate insulin production', 'C': 'Increased osmolal gap', 'D': 'Starvation', 'E': 'Thiamine deficiency'},
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A: Increased acetyl CoA levels
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Answer the following medical question with one of the provided options:
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Q:A 17-year-old girl presents to an urgent care clinic after waking up in the morning with a left-sided facial droop and an inability to fully close her left eye. Of note, she is currently on oral contraceptives and escitalopram and smokes half a pack of cigarettes per day. Her temperature is 98.2°F (36.8°C), blood pressure is 110/68 mmHg, pulse is 82/min, and respirations are 12/min. On exam, she has generalized, unilateral left-sided drooping of her upper and lower face, and an inability to move the left side of her mouth or close her left eye. Her extraocular movements and swallow are intact. She has no other neurologic deficits. Which of the following interventions would most likely address the most likely cause of this patient's symptoms?? {'A': 'Head CT without contrast', 'B': 'Implantation of gold weight for eyelid', 'C': 'Intravenous immunoglobulin', 'D': 'Prednisone alone', 'E': 'Valacyclovir alone'},
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D: Prednisone alone
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Answer the following medical question with one of the provided options:
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Q:A 40-year-old sailor is brought to a military treatment facility 20 minutes after being involved in a navy ship collision. He appears ill. He reports a sensation that he needs to urinate but is unable to void. His pulse is 140/min, respirations are 28/min, and blood pressure is 104/70 mm Hg. Pelvic examination shows ecchymoses over the scrotum and perineum. There is tenderness over the suprapubic region and blood at the urethral meatus. Digital rectal examination shows a high-riding prostate. Abdominal ultrasound shows a moderately distended bladder. X-rays of the pelvis show fractures of all four pubic rami. Which of the following is the most likely cause of this patient's symptoms?? {'A': 'Tearing of the anterior urethra', 'B': 'Rupture of the corpus cavernosum', 'C': 'Rupture of the bladder', 'D': 'Tearing of the posterior urethra', 'E': 'Tearing of the ureter'},
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D: Tearing of the posterior urethra
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Answer the following medical question with one of the provided options:
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Q:A 22-year-old woman presents with progressive hearing loss for the past 4 months. She says that she isn’t hearing high frequency sounds like she used to, especially in large rooms. Her past medical history shows significant bilateral lens dislocations 6 months ago. Family history reveals that her mother had chronic hematuria and her grandfather suffered from corneal dystrophy and died from renal failure at age 51. The vital signs include: blood pressure 145/95 mm Hg, pulse 78/min, and respiratory rate 19/min. On physical examination, the patient has mild to moderate bilateral sensorineural high-frequency hearing loss. A slit-lamp examination is shown in the exhibit (see image). The remainder of the exam is unremarkable. Laboratory findings are significant for microscopic hematuria. Which of the following tests would most likely confirm the diagnosis in this patient?? {'A': 'Renal biopsy', 'B': 'Skin biopsy', 'C': 'Urinary creatinine (24-hour)', 'D': 'Upright KUB radiograph', 'E': 'Renal ultrasound'},
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B: Skin biopsy
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Q:A pregnant woman gives birth to her 1st child at the family farm. After delivery, the assisting midwife notices a triangular defect in the lower anterior abdominal wall of the baby. She clamps the umbilical cord with a cloth and urges the family to seek immediate medical care at the nearest hospital. Upon admission, the attending pediatrician further notices an open bladder plate with an exposed urethra, a low set umbilicus, an anteriorly displaced anus, and an inguinal hernia. No omphalocele is noted. The external genitalia is also affected. On physical exam, a shortened penis with a pronounced upward curvature and the urethral opening along the dorsal surface are also noted. What is the most likely diagnosis?? {'A': 'Urachal cyst', 'B': 'Body stalk anomaly', 'C': 'Posterior urethral valves', 'D': 'Cloacal exstrophy', 'E': 'Bladder exstrophy'},
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E: Bladder exstrophy
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Answer the following medical question with one of the provided options:
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Q:A new drug has been shown to block epithelial sodium channels in the cortical collecting duct. Which of the following is most likely to be decreased upon drug administration?? {'A': 'Potassium secretion in the collecting tubules', 'B': 'Sodium secretion in the collecting tubules', 'C': 'Urea secretion in the collecting tubules', 'D': 'Hydrogen ion reabsorption in the collecting tubules', 'E': 'Sodium chloride reabsorption in the distal tubule'},
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A: Potassium secretion in the collecting tubules
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Q:A 30-year-old G1P0 woman at 26 weeks gestation presents to the obstetric emergency room for an evaluation after being involved in a motor vehicle accident. She was in the passenger seat of her car when the car was hit on the side by a drunk driver. She is currently in no acute distress but is worried about her pregnancy. The patient attended all her prenatal visits and took all her appropriate prenatal vitamins. Her past medical history is notable for diabetes mellitus, for which she takes metformin. Her temperature is 98.6°F (37°C), blood pressure is 135/75 mmHg, pulse is 109/min, and respirations are 22/min. A non-stress test is non-responsive, and a biophysical profile demonstrates abnormal fetal breathing, fetal activity, and fetal muscle tone. An amniotic fluid sample is taken which demonstrates a lecithin/sphingomyelin ratio of 1.9. Which of the following is the next best step in the management of this patient?? {'A': 'Betamethasone administration', 'B': 'Emergent cesarean section', 'C': 'Contraction stress test', 'D': 'Immediate induction of labor', 'E': 'Repeat biophysical profile'},
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A: Betamethasone administration
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Q:A 56-year-old woman presents to the emergency department following a seizure episode. She has a remote history of tonic-clonic seizures; however, her seizures have been well-controlled on valproate, with no seizure episodes occurring over the past 12 years. She was weaned off of the valproate 4 months ago. Her temperature is 97.6°F (36.4°C), blood pressure is 122/80 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 99% on room air. Examination reveals her to be lethargic and somewhat confused. She is moving all extremities spontaneously. Her mucous membranes appear moist and she does not demonstrate any skin tenting. Laboratory values are ordered as seen below. Arterial blood gas pH: 7.21 PO2: 99 mmHg PCO2: 20 mmHg HCO3-: 10 meq/L The patient's initial serum chemistries and CBC are otherwise unremarkable except for the bicarbonate as indicated above. An ECG demonstrates normal sinus rhythm. Which of the following is the best next step in management for this patient's acid-base status?? {'A': 'Dialysis', 'B': 'Intubation', 'C': 'Normal saline', 'D': 'Observation', 'E': 'Sodium bicarbonate'},
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D: Observation
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Q:A 13-year-old girl is brought to the physician by her mother because of a 1-month history of abnormal movements of her muscles that she cannot control. She has a younger brother with cognitive disabilities and epilepsy. Examination shows frequent, brief, involuntary contractions of the muscle groups of the upper arms, legs, and face that can be triggered by touch. An EEG shows generalized epileptiform activity. A trichrome stain of a skeletal muscle biopsy specimen shows muscle fibers with peripheral red inclusions that disrupt the normal fiber contour. Which of the following is the most likely underlying mechanism of the patient's symptoms?? {'A': 'CTG trinucleotide repeat expansion', 'B': 'Mutation of the methyl-CpG binding protein 2 gene', 'C': 'Defective oxidative phosphorylation', 'D': 'Autoimmune endomysial destruction', 'E': 'Truncated dystrophin protein'},
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C: Defective oxidative phosphorylation
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Q:A 70-year-old man with a history of chronic constipation presents to the emergency department with a two-day history of left lower quadrant abdominal pain. He is found to have a temperature of 100.8F, BP 140/90, HR 85, and RR 16. On physical examination, he is tender to light palpation in the left lower quadrant and exhibits voluntary guarding. Rectal examination reveals heme-positive stool. Laboratory values are unremarkable except for a WBC count of 12,500 with a left shift. Which of the following tests would be most useful in the diagnosis of this patient's disease?? {'A': 'Abdominal x-ray', 'B': 'Lipase', 'C': 'Abdominal CT', 'D': 'Left lower quadrant ultrasound', 'E': 'Emergent colonoscopy'},
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C: Abdominal CT
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Q:A 28-year-old man presents to the clinic with increasing shortness of breath, mild chest pain at rest, and fatigue. He normally lives a healthy lifestyle with moderate exercise and an active social life, but recently he has been too tired to do much. He reports that he is generally healthy and on no medications but did have a ‘cold’ 2 weeks ago. He does not smoke, besides occasional marijuana with friends, and only drinks socially. His father has hypertension, hyperlipidemia, and lung cancer after a lifetime of smoking, and his mother is healthy. He also has one older brother with mild hypertension. His pulse is 104/min, the respiratory rate 23/min, the blood pressure 105/78 mm Hg, and the temperature 37.1°C (98.8°F). On physical examination, he is ill-appearing and has difficulty completing sentences. On auscultation he has a third heart sound, and his point of maximal impact is displaced laterally. He has 2+ pitting edema of the lower extremities up to the knees. An ECG is obtained and shows premature ventricular complexes and mildly widened QRS complexes. An echocardiogram is also performed and shows global hypokinesis with a left ventricle ejection fraction of 39%. Of the following, what is the most likely cause of his symptoms?? {'A': 'Acute myocardial infarction', 'B': 'Unstable angina', 'C': 'Coxsackievirus infection', 'D': 'Amyloidosis', 'E': 'Cocaine abuse'},
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C: Coxsackievirus infection
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Q:A 45-year-old man comes to the physician because of a 1-month history of fever and poor appetite. Five weeks ago, he underwent molar extraction for dental caries. His temperature is 38°C (100.4°F). Cardiac examination shows a grade 2/6 holosystolic murmur heard best at the apex. A blood culture shows gram-positive, catalase-negative cocci. Transesophageal echocardiography shows a small vegetation on the mitral valve with mild regurgitation. The causal organism most likely has which of the following characteristics?? {'A': 'Production of CAMP factor', 'B': 'Replication in host macrophages', 'C': 'Formation of germ tubes at body temperature', 'D': 'Production of dextrans', 'E': 'Conversion of fibrinogen to fibrin'},
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D: Production of dextrans
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Q:A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?? {'A': 'Cyclothymic disorder', 'B': 'Bipolar I disorder', 'C': 'Bipolar II disorder', 'D': 'Persistent depressive disorder', 'E': 'Dysthymic disorder'},
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A: Cyclothymic disorder
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Q:A 24-year-old woman presents with a 3-month history of worsening insomnia and anxiety. She says that she has an important college exam in the next few weeks for which she has to put in many hours of work each day. Despite the urgency of her circumstances, she states that she is unable to focus and concentrate, is anxious, irritable and has lost interest in almost all activities. She also says that she has trouble falling asleep and wakes up several times during the night. She claims that this state of affairs has severely hampered her productivity and is a major problem for her, and she feels tired and fatigued all day. She denies hearing voices, abnormal thoughts, or any other psychotic symptoms. The patient asks if there is some form of therapy that can help her sleep better so that she can function more effectively during the day. She claims that the other symptoms of not enjoying anything, irritability, and anxiety are things that she can learn to handle. Which of the following approaches is most likely to address the patients concerns most effectively?? {'A': 'Psychotherapy only', 'B': 'Initiation of risperidone', 'C': 'Trial of bupropion', 'D': 'Dose titration of mirtazapine', 'E': 'Phototherapy'},
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D: Dose titration of mirtazapine
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Q:A 39-year-old man comes to the physician for preoperative evaluation. He is scheduled for a right inguinal hernia repair the following day. He has a history of polycystic kidney disease and hypertension. His medications include lisinopril and vitamin D3 supplements. His father had the same kidney condition and died of an intracerebral aneurysm when the patient was 2 years old. His temperature is 37°C (98.6 F), pulse is 87/min, and blood pressure is 108/68 mm Hg. He has bilateral pitting edema. There is a right inguinal hernia; cough impulse is present. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 9.0 g/dL Serum Na+ 132 mEq/L K+ 6.5 mEq/L Cl- 94 mEq/L HCO3- 21 mEq/L Glucose 86 mg/dL Creatinine 2.9 mg/dL Calcium 8.7 mg/dL Phosphorus 4.9 mg/dL An ECG shows tall T waves. Intravenous calcium gluconate is administered. Which of the following is the definitive treatment for this patient?"? {'A': 'Perform hemodialysis', 'B': 'Restrict salt and potassium intake', 'C': 'Administer sodium bicarbonate', 'D': 'Administer insulin and glucose', 'E': 'Packed red blood cell transfusion'},
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A: Perform hemodialysis
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Q:A 32-year-old nulligravid woman comes to the physician because of 2 weeks of postcoital pain and blood-tinged vaginal discharge. She has been sexually active with one male partner for the past 3 months. They do not use condoms. Her only medication is a combined oral contraceptive that she has been taking for the past 2 years. She states that she takes the medication fairly consistently, but may forget a pill 2–3 days per month. One year ago, her Pap smear was normal. She has not received the HPV vaccine. The cervix is tender to motion on bimanual exam. There is bleeding when the cervix is touched with a cotton swab during speculum exam. Which of the following is the most likely diagnosis?? {'A': 'Cervix trauma', 'B': 'Uterine leiomyomas', 'C': 'Breakthrough bleeding', 'D': 'Early uterine pregnancy', 'E': 'Chlamydia infection'},
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E: Chlamydia infection
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Q:A 55-year-old male presents to his primary care physician for a normal check-up. He has a history of atrial fibrillation for which he takes metoprolol and warfarin. During his last check-up, his international normalized ratio (INR) was 2.5. He reports that he recently traveled to Mexico for a business trip where he developed a painful red rash on his leg. He was subsequently prescribed an unknown medication by a local physician. The rash resolved after a few days and he currently feels well. His temperature is 98.6°F (37°C), blood pressure is 130/80 mmHg, pulse is 95/min, and respirations are 18/min. Laboratory analysis reveals that his current INR is 4.5. Which of the following is the most likely medication this patient took while in Mexico?? {'A': 'Rifampin', 'B': 'Trimethoprim-sulfamethoxazole', 'C': 'Griseofulvin', 'D': 'Phenobarbital', 'E': 'St. John’s wort'},
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B: Trimethoprim-sulfamethoxazole
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Q:A 4-year-old boy is brought to the physician by his parents for bedwetting. He went 3 months without wetting the bed but then started again 6 weeks ago. He has been wetting the bed about 1–2 times per week. He has not had daytime urinary incontinence or dysuria. His teachers report that he is attentive in preschool and plays well with his peers. He is able to name 5 colors, follow three-step commands, and recite his address. He can do a somersault, use scissors, and copy a square. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?? {'A': 'Enuresis alarm', 'B': 'Oxybutynin therapy', 'C': 'Bladder ultrasound', 'D': 'Reassurance', 'E': 'IQ testing'},
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D: Reassurance
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Q:An 8-year-old girl is brought to the physician because of a progressive swelling of her neck for the past 6 months. She has no pain, dyspnea, or dysphagia. She is at the 60th percentile for height and the 55th percentile for weight. Vital signs are within normal limits. Examination shows a 3-cm cystic, nontender swelling in the midline of the neck. The swelling moves upwards on protrusion of the tongue. There is no cervical lymphadenopathy. Her serum thyroid-stimulating hormone level is 2.1 μU/mL. Which of the following is the most appropriate next step in management?? {'A': 'Excision of the cyst, track and hyoid bone', 'B': 'Ultrasonography of the neck', 'C': 'CT scan of the neck', 'D': 'Excision of the cyst', 'E': 'Thyroid scintigraphy'},
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B: Ultrasonography of the neck
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Q:A 76-year-old woman presents to the physician for a follow-up examination. She had a hemoglobin level of 10.5 g/dL last month. She complains of mild dyspnea with exercise. She reports exercising daily for the past 30 years. She is relatively healthy without any significant past medical history. She occasionally takes ibuprofen for knee pain. She denies a prior history of alcohol or tobacco use. Her temperature is 37.1°C (98.8°F), the pulse is 65/min, the respiratory rate is 13/min, and the blood pressure is 115/65 mm Hg. The examination shows no abnormalities. Laboratory studies show: Laboratory test Hemoglobin 10.5 g/dL Mean corpuscular volume 75 μm3 Leukocyte count 6500/mm3 with a normal differential Platelet 400,000/mm3 Serum Iron 35 Total iron-binding capacity 450 μg/dL Ferritin 8 Ca+ 9.0 mg/dL Albumin 3.9 g/dL Urea nitrogen 10 mg/dL Creatinine 0.9 mg/dL Serum protein electrophoresis and immunofixation show a monoclonal protein of 20 g/L (non-IgM). Marrow plasmacytosis is 5%. A skeletal survey shows no abnormalities. In addition to the workup of iron deficiency anemia, which of the following is the most appropriate next step in management?? {'A': 'Annual follow-up with laboratory tests', 'B': 'Check beta-2 microglobulin', 'C': 'Referral for induction therapy', 'D': 'Referral for radiation therapy', 'E': 'No further steps are required at this time'},
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A: Annual follow-up with laboratory tests
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Q:A 52-year-old man presents to his primary care physician for a yearly checkup complaining of recent weight gain. The patient states that he has noticed that, regardless of his diet, his midsection has gotten increasingly larger and his old clothes no longer fit. The patient has a 2-year history of left hip arthritis from a car accident for which he is on prednisone, as well as a history of migraine headaches. The patient has also noticed that in the last 2 months, he has developed acne and his face has become fuller in appearance. On exam, the patient has gained 26 pounds since his previous checkup 1 year prior, and he now has a BMI 28.2 kg/m^2 (up from 24.1 kg/m^2 previously). His temperature is 98.3°F (36.8°C), blood pressure is 134/94 mmHg, pulse is 72/min, and respirations are 12/min. His physical exam is notable for red striae on his shoulders and around his waist. On his labs, the patient’s serum ACTH is found to be decreased. Which of the following changes is most likely expected?? {'A': 'Bilateral adrenal atrophy', 'B': 'Bilateral adrenal hyperplasia', 'C': 'Lung malignancy', 'D': 'Unilateral adrenal atrophy', 'E': 'Unilateral adrenal hyperplasia'},
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A: Bilateral adrenal atrophy
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Q:A 35-year-old woman comes to the physician with right-sided flank pain and blood in her urine for 1 day. She does not have fever or dysuria. She had similar symptoms several weeks ago but did not seek medical care at the time. Physical examination shows right costovertebral angle tenderness. Her serum uric acid level is 6.9 mg/dL. Urine dipstick shows 3+ blood. Analysis of a 24-hour urine collection specimen shows wedge-shaped prisms. This patient is most likely to benefit from which of the following to prevent recurrence of her condition?? {'A': 'Low-potassium diet', 'B': 'Amoxicillin with clavulanic acid', 'C': 'Dietary calcium restriction', 'D': 'Allopurinol', 'E': 'Chlorthalidone'},
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E: Chlorthalidone
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Q:A 24-year-old man presents to the emergency department after a motor vehicle accident. The patient was at a stop when he was rear-ended from behind by a vehicle traveling at 11 miles per hour. The patient complains of severe back pain but states he otherwise feels well. The patient is currently seeing a physical therapist who is giving him exercises to alleviate the back pain that is present every morning, relived by activity, and worse with inactivity. He is a student at the university and is struggling with his grades. His temperature is 98.4°F (36.9°C), blood pressure is 117/78 mmHg, pulse is 116/min, respirations are 12/min, and oxygen saturation is 99% on room air. Physical exam demonstrates a decreased range of motion of the patient's spine and tenderness to palpation over the vertebrae. The rest of the exam is deferred due to pain. The patient is requesting a note to excuse him from final exams and work. Which of the following is the most likely diagnosis in this patient?? {'A': 'Herniated nucleus pulposus', 'B': 'Malingering', 'C': 'Musculoskeletal strain', 'D': 'Spondylolisthesis', 'E': 'Vertebral fracture'},
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E: Vertebral fracture
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Q:A 58-year-old male with a history of congestive heart failure and hypertension comes to you with the chief complaint of new-onset cough as well as increased serum potassium in the setting of a new medication. Which of the following medications is most likely responsible for these findings?? {'A': 'Furosemide', 'B': 'Metoprolol', 'C': 'Amiodarone', 'D': 'Digoxin', 'E': 'Lisinopril'},
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E: Lisinopril
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Q:An 11-year-old boy is brought to his pediatrician by his parents for the routine Tdap immunization booster dose that is given during adolescence. Upon reviewing the patient’s medical records, the pediatrician notes that he was immunized according to CDC recommendations, with the exception that he received a catch-up Tdap immunization at the age of 8 years. When the pediatrician asks the boy’s parents about this delay, they inform the doctor that they immigrated to this country 3 years ago from Southeast Asia, where the child had not been immunized against diphtheria, tetanus, and pertussis. Therefore, he received a catch-up series at 8 years of age, which included the first dose of the Tdap vaccine. Which of the following options should the pediatrician choose to continue the boy’s immunization schedule?? {'A': 'A single dose of Tdap vaccine at 13 years of age', 'B': 'A single dose of Tdap vaccine now', 'C': 'A single dose of Tdap vaccine at 18 years of age', 'D': 'A single dose of Td vaccine now', 'E': 'A single dose of Td vaccine at 18 years of age'},
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E: A single dose of Td vaccine at 18 years of age
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Q:A 64-year-old woman with a past medical history of poorly managed diabetes presents to the emergency department with nausea and vomiting. Her symptoms started yesterday and have been progressively worsening. She is unable to eat given her symptoms. Her temperature is 102°F (38.9°C), blood pressure is 115/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for left-sided costovertebral angle tenderness, and urinalysis demonstrates bacteriuria and pyuria. The patient is admitted to the hospital and started on IV ceftriaxone. On day 3 of her hospital stay she is afebrile, able to eat and drink, and feels better. Which of the following antibiotic regimens should be started or continued as an outpatient upon discharge?? {'A': 'Amoxicillin', 'B': 'Ceftriaxone', 'C': 'Meropenem', 'D': 'Nitrofurantoin', 'E': 'Trimethoprim-sulfamethoxazole'},
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E: Trimethoprim-sulfamethoxazole
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Q:A 58-year-old woman with New York Heart Association Class III heart failure, atrial fibrillation, and bipolar disorder presents to the urgent care center with nausea, vomiting, abdominal pain, double vision, and describes seeing green/yellow outlines around objects. Her current medications include ramipril, bisoprolol, spironolactone, digoxin, amiodarone, and lithium. Of the following, which medication is most likely responsible for her symptoms?? {'A': 'Spironolactone', 'B': 'Digoxin', 'C': 'Amiodarone', 'D': 'Lithium', 'E': 'Bisoprolol'},
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B: Digoxin
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Q:A 7-year-old boy is brought in to clinic by his parents with a chief concern of poor performance in school. The parents were told by the teacher that the student often does not turn in assignments, and when he does they are partially complete. The child also often shouts out answers to questions and has trouble participating in class sports as he does not follow the rules. The parents of this child also note similar behaviors at home and have trouble getting their child to focus on any task such as reading. The child is even unable to watch full episodes of his favorite television show without getting distracted by other activities. The child begins a trial of behavioral therapy that fails. The physician then tries pharmacological therapy. Which of the following is most likely the mechanism of action of an appropriate treatment for this child's condition?? {'A': 'Increases the frequency of GABAa channel opening', 'B': 'Increases the duration of GABAa channel opening', 'C': 'Antagonizes NMDA receptors', 'D': 'Decreases synaptic reuptake of norepinephrine and dopamine', 'E': 'Blockade of D2 receptors'},
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D: Decreases synaptic reuptake of norepinephrine and dopamine
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Q:A 54-year-old woman comes to the emergency department because of two episodes of bright red blood per rectum within the past day. She has a history of migraine, which is treated prophylactically with verapamil. She appears well and is hemodynamically stable. Cardiac exam reveals a regular heart rate without any murmurs or gallops. Lungs are clear to auscultation. Her abdomen is mildly tender without rebound or guarding. Digital rectal examination shows fresh blood on the glove. Laboratory studies show: Hemoglobin 10.4 g/dL Leukocyte count 5,000/mm3 Platelet count 175,000/mm3 Partial thromboplastin time 35 seconds Serum Na+ 140 mEq/L K+ 3.7 mEq/L Cl- 101 mEq/L HCO3- 25 mEq/L Mg2+ 1.8 mEq/L A routine ECG shows a heart rate of 75/min, a normal axis, PR interval of 280 ms, QRS interval of 80 ms with a QRS complex following each p wave, and no evidence of ischemic changes. Which of the following is the most appropriate next step in management with respect to this patient's cardiovascular workup?"? {'A': 'Atropine therapy', 'B': 'Observation', 'C': 'Synchronized cardioversion', 'D': 'Metoprolol therapy', 'E': 'Pacemaker placement'},
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B: Observation
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Q:A 28-year-old male intern is currently on a trauma surgery service. After a busy overnight shift, the intern did not have enough time to prepare to present all of the patients on the team’s list. At morning rounds, the chief resident made a sarcastic comment that the intern “really put a lot of effort into preparing for rounds.” After rounds, while managing the floor with the third year medical student, the intern berates the student that she “needs to step up her game and do a better job helping with pre-rounding in the morning.” What type of ego defense is most relevant in this situation?? {'A': 'Denial', 'B': 'Displacement', 'C': 'Passive aggression', 'D': 'Projection', 'E': 'Reaction formation'},
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B: Displacement
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Q:A 35-year-old man is brought to the emergency department by his wife. She was called by his coworkers to come and pick him up from work after he barged into the company’s board meeting and was being very disruptive as he ranted on about all the great ideas he had for the company. When they tried to reason with him, he became hostile and insisted that he should be the CEO as he knew what was best for the future of the company. The patient’s wife also noted that her husband has been up all night for the past few days but assumed that he was handling a big project at work. The patient has no significant past medical or psychiatric history. Which of the following treatments is most likely to benefit this patient’s condition?? {'A': 'Valproic acid', 'B': 'Antidepressants', 'C': 'Psychotherapy', 'D': 'Haloperidol', 'E': 'Clozapine'},
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A: Valproic acid
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Q:An 82-year-old man is brought to the emergency department because of severe pain and joint stiffness in his right knee. The pain started 3 days ago and has worsened despite acetaminophen intake. He has benign prostatic hyperplasia and hypertension. One week ago, he had a urinary tract infection and was treated with nitrofurantoin. He does not smoke or drink alcohol. His current medications include enalapril, hydrochlorothiazide, and tamsulosin. He appears to be in severe pain and has trouble moving his right knee. His temperature is 38.7°C (101.5°F), pulse is 92/min, and blood pressure is 135/90 mm Hg. Physical examination shows a swollen, erythematous, warm right knee; range of motion is limited by pain. Synovial fluid aspiration shows a yellow-green turbid fluid. Gram stain of the synovial aspirate shows numerous leukocytes and multiple gram-negative rods. An x-ray of the right knee shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?? {'A': 'IV nafcillin', 'B': 'IV vancomycin and ceftazidime', 'C': 'IV cefepime', 'D': 'IV ceftazidime and gentamicin', 'E': 'IV vancomycin'},
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C: IV cefepime
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Answer the following medical question with one of the provided options:
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Q:A 27-year-old female ultramarathon runner presents to the physician with complaints of persistent knee pain. She describes the pain to be located in the anterior area of her knee and is most aggravated when she performs steep descents down mountains, though the pain is present with running on flat roads, walking up and down stairs, and squatting. Which of the following would most likely be an additional finding in this patient’s physical examination?? {'A': 'Excessive anterior displacement of the tibia', 'B': 'Excessive posterior displacement of the tibia', 'C': 'Pain upon compression of the patella while the patient performs flexion and extension of the leg', 'D': 'Pain upon pressure placed on the lateral aspect of the knee', 'E': 'Pain upon pressure placed on the medial aspect of the knee'},
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C: Pain upon compression of the patella while the patient performs flexion and extension of the leg
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Q:A 17-year-old high school student comes to the physician because of a 6-month history of insomnia. On school nights, he goes to bed around 11 p.m. but has had persistent problems falling asleep and instead studies at his desk until he feels sleepy around 2 a.m. He does not wake up in the middle of the night. He is worried that he does not get enough sleep. He has significant difficulties waking up on weekdays and has repeatedly been late to school. At school, he experiences daytime sleepiness and drinks 1–2 cups of coffee in the mornings. He tries to avoid daytime naps. On the weekends, he goes to bed around 2 a.m. and sleeps in until 10 a.m., after which he feels rested. He has no history of severe illness and does not take medication. Which of the following most likely explains this patient's sleep disorder?? {'A': 'Delayed sleep-wake disorder', 'B': 'Psychophysiologic insomnia', 'C': 'Advanced sleep-wake disorder', 'D': 'Irregular sleep-wake disorder', 'E': 'Inadequate sleep hygiene'},
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A: Delayed sleep-wake disorder
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Q:A 45-year-old woman from Mexico comes to your office due to recent shortness of breath. The patient states that she has recently started having trouble breathing when she is working out, but this resolves when she rests for a while. She states that she has no history of diabetes, heart disease, or hypertension, but does state that she had several colds when she was growing up that weren't treated with antibiotics. Furthermore, she has arthritis in one of her knees and both wrists. On exam, her vitals are normal, but there is a mid-diastolic rumble present at the apex. What is the best definitive treatment for this patient?? {'A': 'Diuretics', 'B': 'Beta-blockers', 'C': 'Valve replacement', 'D': 'Percutaneous valve commissurotomy', 'E': 'Open valve commissurotomy'},
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D: Percutaneous valve commissurotomy
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Q:A 37-year-old woman comes to the physician because of a 10-month history of excessive daytime sleepiness and fatigue. She says she has difficulty concentrating and has fallen asleep at work on numerous occasions. She also reports having frequent headaches during the day. She has no difficulty falling asleep at night, but wakes up gasping for breath at least once. She has always snored loudly and began using an oral device to decrease her snoring a year ago. She has occasional lower back pain, for which she takes tramadol tablets 1–2 times per week. She also began taking one rabeprazole tablet daily 3 weeks ago. She does not smoke. She is 175 cm (5 ft 7 in) tall and weighs 119 kg (262 lb); BMI is 38.8 kg/m2. Her vital signs are within normal limits. Physical and neurologic examinations show no other abnormalities. Arterial blood gas analysis on room air shows: pH 7.35 PCO2 51 mm Hg PO2 64 mm Hg HCO3- 29 mEq/L O2 saturation 92% An x-ray of the chest and ECG show no abnormalities. Which of the following is the most likely cause of this patient's condition?"? {'A': 'Apneic episodes with obstructed upper airways', 'B': 'Drug-induced respiratory depression', 'C': 'Chronic inflammatory airflow limitation', 'D': 'Thickening of alveolar membranes', 'E': 'Diurnal alveolar hypoventilation\n"'},
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E: Diurnal alveolar hypoventilation "
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Q:A 77-year-old female comes to a medical school's free clinic for follow-up examination after a urinary tract infection (UTI) and is seen by a fourth year medical student. The clinic serves largely uninsured low-income patients in a New York City neighborhood with a large African American and Latino population. Two weeks ago, the patient was treated in the local emergency department where she presented with altered mental state and dysuria. The medical student had recently read about a study that described a strong relationship between cognitive impairment and UTI hospitalization risk (RR = 1.34, p < 0.001). The attending physician at the medical student's free clinic is also familiar with this study and tells the medical student that the study was conducted in a sample of upper middle class Caucasian patients in the Netherlands. The attending states that the results of the study should be interpreted with caution. Which of the following concerns is most likely underlying the attending physician's remarks?? {'A': 'Confounding bias', 'B': 'Low internal validity', 'C': 'Poor reliability', 'D': 'Low external validity', 'E': 'Selection bias'},
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D: Low external validity
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Q:An investigator is studying the biology of human sperm cells. She isolates spermatogonia obtained on a testicular biopsy from a group of healthy male volunteers. She finds that the DNA of spermatogonia obtained from these men show a large number of TTAGGG sequence repeats. This finding can best be explained by increased activity of an enzyme with which of the following functions?? {'A': 'Ligation of Okazaki fragments', 'B': 'Hemimethylation of DNA strand', 'C': 'Proofreading of synthesized daughter strands', 'D': 'RNA-dependent synthesis of DNA', 'E': 'Production of short RNA sequences'},
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D: RNA-dependent synthesis of DNA
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Q:A 44-year-old woman with high blood pressure and diabetes presents to the outpatient clinic and informs you that she is trying to get pregnant. Her current medications include lisinopril, metformin, and sitagliptin. Her blood pressure is 136/92 mm Hg and heart rate is 79/min. Her physical examination is unremarkable. What should you do regarding her medication for high blood pressure?? {'A': 'Continue her current regimen', 'B': 'Discontinue lisinopril and initiate labetalol', 'C': 'Continue her current regimen and add a beta-blocker for increased control', 'D': 'Discontinue lisinopril and initiate candesartan', 'E': 'Discontinue lisinopril and initiate aliskiren'},
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B: Discontinue lisinopril and initiate labetalol
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Answer the following medical question with one of the provided options:
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Q:A 67-year-old man comes to the physician for a routine examination. He does not take any medications. He drinks 6 to 7 bottles of beer every night, and says he often has a shot of whiskey in the morning “for my headache.” He was recently fired from his job for arriving late. He says there is nothing wrong with his drinking but expresses frustration at his best friend no longer returning his calls. Which of the following is the most appropriate initial response by the physician?? {'A': '"""I\'m sorry that your friend no longer returns your calls. It seems like your drinking is affecting your close relationships."""', 'B': '"""I\'m sorry to hear you lost your job. Drinking the amount of alcohol that you do can have very negative effects on your health."""', 'C': '"""I\'m sorry that your friend no longer returns your calls. What do you think your friend is worried about?"""', 'D': '"""I\'m sorry that your friend no longer returns your calls. Do you feel that your drinking has affected your relationship with your friend?"""', 'E': '"""I\'m sorry to hear you lost your job. I am concerned about the amount of alcohol you are drinking."""'},
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C: """I'm sorry that your friend no longer returns your calls. What do you think your friend is worried about?"""
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Answer the following medical question with one of the provided options:
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Q:A 42-year-old woman comes to the physician because of a 5-day history of intermittent palpitations. She has no history of syncope or chest pain. She had similar symptoms 1 year ago and following workup has been treated with daily flecainide since then. She drinks one to two glasses of wine on the weekends. She does not smoke. Her pulse is 71/min and her blood pressure is 134/72 mm Hg. A complete blood count shows no abnormalities. Serum creatinine, electrolytes, and TSH are within normal limits. An ECG is shown. Ablation near which of the following sites would be most appropriate for long-term management of this patient's condition?? {'A': 'Basal interventricular septum', 'B': 'Pulmonary vein openings', 'C': 'Atrioventricular node', 'D': 'Cavotricuspid isthmus', 'E': 'Bundle of Kent'},
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B: Pulmonary vein openings
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Answer the following medical question with one of the provided options:
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Q:A 51-year-old woman with hyperlipidemia comes to the physician because of weakness for one month. At the end of the day, she feels too fatigued to cook dinner or carry a laundry basket up the stairs. She also complains of double vision after she reads for long periods of time. All of her symptoms improve with rest. Her only medication is pravastatin. Physical examination shows drooping of the upper eyelids. Strength is initially 5/5 in the upper and lower extremities but decreases to 4/5 after a few minutes of sustained resistance. Sensation to light touch is intact and deep tendon reflexes are normal. Which of the following best describes the pathogenesis of this patient's condition?? {'A': 'Type II hypersensitivity reaction', 'B': 'Peripheral nerve demyelination', 'C': 'Impaired acetylcholine release', 'D': 'Adverse drug effect', 'E': 'Anterior horn cell destruction'},
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A: Type II hypersensitivity reaction
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Answer the following medical question with one of the provided options:
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Q:A 65-year-old man comes to the physician because of increasing swelling of the legs and face over the past 2 months. He has a history of diastolic heart dysfunction. The liver and spleen are palpable 4 cm below the costal margin. On physical examination, both lower limbs show significant pitting edema extending above the knees and to the pelvic area. Laboratory studies show: Serum Cholesterol 350 mg/dL (<200 mg/dL) Triglycerides 290 mg/dL (35–160 mg/dL) Calcium 8 mg/dL Albumin 2.8 g/dL Urea nitrogen 54 mg/dL Creatinine 2.5 mg/dL Urine Blood 3+ Protein 4+ RBC 15–17/hpf WBC 1–2/hpf RBC casts Many Echocardiography shows concentrically thickened ventricles with diastolic dysfunction. Skeletal survey shows no osteolytic lesions. Which of the following best explains these findings?? {'A': 'AL amyloidosis', 'B': 'Monoclonal gammopathy of undetermined significance', 'C': 'Smoldering multiple myeloma', 'D': 'Symptomatic multiple myeloma', 'E': 'Waldenstrom’s macroglobulinemia'},
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A: AL amyloidosis
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Answer the following medical question with one of the provided options:
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Q:A 45-year-old woman comes to the physician because of early satiety and intermittent nausea for 3 months. During this period she has also felt uncomfortably full after meals and has vomited occasionally. She has not had retrosternal or epigastric pain. She has longstanding type 1 diabetes mellitus, diabetic nephropathy, and generalized anxiety disorder. Current medications include insulin, ramipril, and escitalopram. Vital signs are within normal limits. Examination shows dry mucous membranes and mild epigastric tenderness. Her hemoglobin A1C concentration was 12.2% 3 weeks ago. Which of the following drugs is most appropriate to treat this patient's current condition?? {'A': 'Omeprazole', 'B': 'Clarithromycin', 'C': 'Metoclopramide', 'D': 'Ondansetron', 'E': 'Calcium carbonate\n"'},
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C: Metoclopramide
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