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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 with type 2 diabetes mellitus comes to the physician for a follow-up examination. He reports that he has been compliant with his current antidiabetic medication regimen. His hemoglobin A1c concentration is 8.5%. The physician prescribes a drug that reversibly inhibits a membrane-bound enzyme that hydrolyzes carbohydrate bonds. Which of the following drugs was most likely added to this patient's medication regimen?? {'A': 'Linagliptin', 'B': 'Canagliflozin', 'C': 'Pramlintide', 'D': 'Miglitol', 'E': 'Rosiglitazone'},
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D: Miglitol
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Answer the following medical question with one of the provided options:
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Q:A 60-year-old woman is brought to the emergency department by paramedics after being found unresponsive. It is not possible to obtain a history. Her blood pressure is 75/30 mmHg and pulse is 108/min. Her extremities are cool and mottled. She admitted to the intensive care unit (ICU) for further supportive care, where she is started on a norepinephrine intravenous drip. After several hours on this infusion, which of the following changes in vitals would be expected?? {'A': 'Blood pressure increases; pulse increases', 'B': 'Blood pressure decreases; pulse decreases', 'C': 'Blood pressure increases; pulse decreases', 'D': 'Blood pressure decreases; pulse increases', 'E': 'Blood pressure increases; pulse remains unchanged'},
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C: Blood pressure increases; pulse decreases
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Answer the following medical question with one of the provided options:
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Q:A 62-year-old man with a history of coronary artery disease comes to the emergency department with substernal chest pain for several hours. An ECG shows no abnormalities. Troponin T test results are negative. The patient is admitted to the hospital and treated with intravenous nitroglycerin, with an initial resolution of his symptoms. After 6 hours of continuous infusion of nitroglycerin, he reports increasing chest pain. The underlying cause of this patient's recurrent symptoms is most likely to also occur in treatment with which of the following drugs?? {'A': 'Levodopa', 'B': 'Alprazolam', 'C': 'Phenylephrine', 'D': 'Methicillin', 'E': 'Hydrocodone'},
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C: Phenylephrine
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Answer the following medical question with one of the provided options:
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Q:A 21-year-old man presents to the clinic complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. What is this patient's diagnosis?? {'A': 'Insomnia', 'B': 'Obstructive sleep apnea (OSA)', 'C': 'Delayed sleep phase syndrome (DSPS)', 'D': 'Narcolepsy', 'E': 'Alcohol withdrawal'},
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D: Narcolepsy
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Answer the following medical question with one of the provided options:
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Q:A 43-year-old man presents to a primary care clinic complaining of several months of fatigue and difficulty concentrating at work. He is tired throughout the day and often falls asleep briefly at work. He sleeps for 9 hours per night, falling asleep easily, waking up several times in the middle of the night, and then having trouble waking up in the morning. Physical exam is notable for obesity and a large neck circumference. His temperature is 98°F (36.7°C), blood pressure is 150/90 mmHg, pulse is 75/min, respirations are 22/min, and BMI is 33 kg/m^2. The rest of the physical exam is normal. Which of the following is the most likely cause of his fatigue?? {'A': 'Chronic fatigue syndrome', 'B': 'Circadian rhythm sleep wake disorder', 'C': 'Hypothyroidism', 'D': 'Narcolepsy', 'E': 'Obstructive sleep apnea'},
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E: Obstructive sleep apnea
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Answer the following medical question with one of the provided options:
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Q:A 78-year-old man comes to the physician because of a change in his voice. His wife says his voice has progressively become higher pitched, and he has had a 5.4-kg (11.9-lb) weight loss over the past 4 months. He has smoked half a pack of cigarettes daily for the past 40 years. Direct laryngoscopy shows an irregular, nodular glottic mass. A biopsy specimen of the mass shows poorly differentiated squamous cells with nuclear atypia, hyperkeratosis, and disruption of the basement membrane. Involvement of a muscle derived from which of the following branchial arches is the most likely cause of his symptoms?? {'A': '6th arch', 'B': '2nd arch', 'C': '1st arch', 'D': '3rd arch', 'E': '4th arch'},
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E: 4th arch
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Answer the following medical question with one of the provided options:
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Q:A 63-year-old woman visits her family physician because she has been experiencing difficulty to get her urine stream started in the past 8 months with many occasions needing extra effort to pass the urine. She describes the stream as intermittent and slow, and comments that she needs to go to the restroom again immediately after urinating. Her personal medical history is negative for malignancies, and all of her cytologies have been reported as normal. The only medication she takes is an angiotensin receptor blocker to treat essential hypertension diagnosed 5 years ago. Physical examination is unremarkable except for herniation of the anterior wall of the vagina that goes beyond the hymen. Which of the following types of incontinence is affecting the patient?? {'A': 'Stress incontinence', 'B': 'Urgency incontinence', 'C': 'Mixed incontinence', 'D': 'Overflow incontinence', 'E': 'Functional incontinence'},
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D: Overflow incontinence
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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 is brought to the hospital after being found unresponsive in his bed in the morning. He is declared dead on arrival in the emergency room. His wife states that he always had uncontrolled hypertension despite being on multiple medications. An autopsy is performed, and the cause of his death is found to be a hemorrhage in his right basal ganglia. On microscopic examination, the branches of the renal artery have concentric endothelial proliferation with prominent narrowing of the lumen resulting in focal ischemia and hemorrhage of the renal parenchyma. Which of the following is most likely related to the findings in this patient?? {'A': 'Elevated C-reactive protein in the blood', 'B': 'Raised cholesterol level in the blood', 'C': 'Elevated ammonia level in the blood', 'D': 'Raised calcium level in the blood', 'E': 'Raised renin level in the blood'},
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E: Raised renin level in the blood
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Answer the following medical question with one of the provided options:
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Q:A 68-year-old woman comes to the physician with dysphagia and halitosis for several months. She feels food sticking to her throat immediately after swallowing. Occasionally, she regurgitates undigested food hours after eating. She has no history of any serious illness and takes no medications. Her vital signs are within normal limits. Physical examination including the oral cavity, throat, and neck shows no abnormalities. Which of the following is the most appropriate diagnostic study at this time?? {'A': 'Barium swallow with video fluoroscopy', 'B': 'Cervical magnetic resonance imaging', 'C': 'Chest computed tomography scan', 'D': 'Chest X-ray', 'E': 'Upper gastrointestinal series'},
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A: Barium swallow with video fluoroscopy
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Answer the following medical question with one of the provided options:
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Q:A 37-year-old woman is brought to the emergency department 15 minutes after falling down a flight of stairs. On arrival, she has shortness of breath, right-sided chest pain, right upper quadrant abdominal pain, and right shoulder pain. She is otherwise healthy. She takes no medications. She appears pale. Her temperature is 37°C (98.6°F), pulse is 115/min, respirations are 20/min, and blood pressure is 85/45 mm Hg. Examination shows several ecchymoses over the right chest. There is tenderness to palpation over the right chest wall and right upper quadrant of the abdomen. Bowel sounds are normal. Cardiopulmonary examination shows no abnormalities. Neck veins are flat. Which of the following is the most likely diagnosis?? {'A': 'Splenic laceration', 'B': 'Small bowel perforation', 'C': 'Pneumothorax', 'D': 'Liver hematoma', 'E': 'Duodenal hematoma'},
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D: Liver hematoma
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Answer the following medical question with one of the provided options:
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Q:An investigator is studying the interaction between epithelial cells and calcium ion concentration. When the calcium ion concentration available to a sample of epithelial tissue is decreased, an increased gap between adjacent epithelial cells is seen on electron microscopy. This observed decrease in cell adhesion is most likely due to an effect on which of the following proteins?? {'A': 'Claudin', 'B': 'Cadherin', 'C': 'Actin', 'D': 'Cytokeratin', 'E': 'Integrin'},
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B: Cadherin
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Answer the following medical question with one of the provided options:
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Q:A 26-year-old man with no past medical history is brought in to the trauma bay by ambulance after sustaining a motorcycle crash against a parked car. The patient is alert and oriented with no focal neurologic defects. The patient has a few lower extremity abrasions but is otherwise healthy and is discharged. One week later, the patient returns to the emergency department with a 2-day history of high fevers and redness on his left lower leg. On exam, his temperature is 102.0°F (38.9°C), blood pressure is 70/44 mmHg, pulse is 108/min, and respirations are 14/min. The patient appears toxic, and his left lower leg is tense, erythematous, and tender to palpation between the ankle and the knee. The exam is notable for tense bullae developing on the lateral calf. Palpation near the bullae is notable for crepitus. Which of the following toxins is likely responsible for this finding?? {'A': 'Alpha toxin', 'B': 'Botulinum toxin', 'C': 'Cytotoxin', 'D': 'Enterotoxin', 'E': 'Tetanospasmin'},
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A: Alpha toxin
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Answer the following medical question with one of the provided options:
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Q:A 5-year-old boy is brought to the office by his mother with complaints of facial puffiness and “frothy” urine for 4 days. The puffiness first started in his eyes and then spread to the face. His mother does not provide any history of similar symptoms in the past. Past medical history is non-significant. His birth history is uneventful and all his vaccinations are up to date. The vital signs include: blood pressure 100/62 mm Hg, pulse 110/min, temperature 36.7°C (98.0°F), and respiratory rate 16/min. On examination, there is pitting edema of the upper and lower extremities bilaterally. Urinalysis results are as follows: pH 6.2 Color light yellow RBC none WBC 3–4/HPF Protein 4+ Cast Fat globules Glucose absent Crystal none Ketone absent Nitrite absent 24-hour urine protein excretion 4.1 g A renal biopsy is sent which shows normal glomeruli on light microscopy. Which of the following is the most likely diagnosis?? {'A': 'Membranoproliferative glomerulonephritis', 'B': 'Post-infectious glomerulonephritis', 'C': 'Focal segmental glomerulosclerosis', 'D': 'Lipoid nephrosis', 'E': 'Membranous nephropathy'},
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D: Lipoid nephrosis
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Answer the following medical question with one of the provided options:
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Q:An 18-year-old woman presents to the medical clinic 6 days after her boyfriend’s condom broke during sexual intercourse. The patient states “I do not wish to get pregnant at this point in my life.” She has no other medical conditions and takes no prescription medications. Her family history is negative. She is a social drinker, drinking approx. 3–4 days every month. She is currently in a monogamous relationship with her boyfriend and she believes her boyfriend is monogamous as well. The heart rate is 104/min, and the blood pressure is 124/80 mm Hg. On physical examination, she appears tiresome and nervous. The heart auscultation is absent of murmur, and the lungs are clear to auscultation bilaterally. Her ovaries and uterus are palpable. Speculum exam shows no signs of trauma and a closed cervical os. Based on her history and physical examination, which of the following management strategies would you recommend?? {'A': 'Mifepristone', 'B': 'Ulipristal acetate', 'C': 'Copper-IUD', 'D': 'Levonorgestrel', 'E': 'Ethinyl estradiol'},
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C: Copper-IUD
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Answer the following medical question with one of the provided options:
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Q:A 68-year-old woman is being evaluated for fatigue during a follow-up visit after implantation of a prosthetic aortic valve a month ago. She reports she has been feeling more tired than usual but associates it with her recent surgery. A complete blood count (CBC) reveals a hemoglobin of 9.5 g/L and a reticulocyte percentage of 2.8%. Additionally, the serum haptoglobin is decreased while the platelet count is within the normal range. The patient is suspected to have a type of hemolytic anemia secondary to her prosthetic heart valve. Which of the following will most likely be seen in this patient’s blood smear?? {'A': 'Dacrocytes', 'B': 'Schistocytes', 'C': 'Basophilic stippling', 'D': 'Acanthocytes', 'E': 'Degmacytes'},
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B: Schistocytes
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Answer the following medical question with one of the provided options:
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Q:A 64-year-old female with type 2 diabetes mellitus comes to the physician because of a 1-week history of painful red swelling on her left thigh. Examination shows a 3- x 4-cm, tender, fluctuant mass. Incision and drainage of the abscess are performed. Culture of the abscess fluid grows gram-positive, coagulase-positive cocci that are resistant to oxacillin. Which of the following best describes the mechanism of resistance of the causal organism to oxacillin?? {'A': 'Degradation of the antibiotic', 'B': 'Decreased uptake of the antibiotic', 'C': 'Acetylation of the antibiotic', 'D': 'Altered target of the antibiotic', 'E': 'Decreased activation of the antibiotic'},
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D: Altered target of the antibiotic
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Answer the following medical question with one of the provided options:
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Q:A 30-year-old female with a history of epilepsy becomes pregnant. Her epilepsy has been well controlled by taking a medication that increases sodium channel inactivation. Her obstetrician informs her that her epilepsy medication has been shown to have teratogenic effects. Of the following, which teratogenic effect is this woman's medication most likely to cause?? {'A': 'Discolored teeth', 'B': 'Renal damage', 'C': 'Limb defects', 'D': "Ebstein's anomaly", 'E': 'Neural tube defect'},
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E: Neural tube defect
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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 comes to the physician because of a 6-month history of a slowly enlarging nodule on the left upper eyelid that has persisted despite treatment with warm compresses. He also reports heaviness of the eyelid and mild blurring of vision in the left eye. Vital signs are within normal limits. Visual acuity is decreased in the left eye. Ophthalmic examination shows a solitary, rubbery, nontender nodule on the central portion of the left upper eyelid. The lesion is better seen on eversion of the left eyelid. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?? {'A': 'Eyelid hygiene', 'B': 'Cryotherapy', 'C': 'Local tetracycline', 'D': 'Biopsy', 'E': 'Mohs micrographic surgery'},
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D: Biopsy
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Answer the following medical question with one of the provided options:
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Q:A 65-year-old male presents to the emergency room complaining of a severe headache. He developed a sudden-onset severe throbbing headache while watching a football game on television. His past medical history is significant for migraines and hypertension; however, he states that this headache is different from his normal migraine headaches. He has a 30 pack-year smoking history. His family history is notable for stroke in his mother and father. His temperature is 98.9°F (37.2°C), blood pressure is 150/90 mmHg, pulse is 100/min, and respirations are 14/min. On examination, he is oriented to person, place, and time. Neck motion is limited due to pain. Strength is 5/5 bilaterally in both the upper and the lower extremities and sensation is grossly intact across all the dermatomal distributions. Patellar, brachioradialis, and Achilles reflexes are 2+ bilaterally. The vessel that is most likely responsible for this patient’s condition directly branches off which of the following vessels?? {'A': 'Anterior cerebral artery', 'B': 'Maxillary artery', 'C': 'Internal carotid artery', 'D': 'Middle cerebral artery', 'E': 'Posterior cerebral artery'},
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A: Anterior cerebral artery
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Answer the following medical question with one of the provided options:
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Q:A 31-year-old woman presents to the clinic with shortness of breath, palpitations, and fatigue. She has had these symptoms over the last several weeks. She had been tolerating these symptoms until last night when she could not fall asleep due to palpitations. She has a past medical history of infective endocarditis 6 months ago that was successfully treated with antibiotics. She does not smoke or drink alcohol. Her blood pressure is 138/89 mm Hg and her pulse is 76/min and regular. The cardiac exam reveals a soft S1, S3 gallop, a hyperdynamic apex beat, and a pansystolic murmur that radiates to the axilla on auscultation. Echocardiography reveals incompetence of one of the valves. Which of the following sites is the best position to auscultate this defect?? {'A': 'Right lower end of the body of the sternum', 'B': '4th intercostal space at the midclavicular line on the left side', 'C': 'Medial end of the 2nd intercostal space on the right side', 'D': '5th intercostal space at the midclavicular line on the left side', 'E': 'Medial end of the 2nd intercostal space on the left side'},
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D: 5th intercostal space at the midclavicular line on the left side
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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 the emergency department because of tingling in his hands and legs and palpitations for 1 week. He has also had severe cramping in his hands, feet, and abdomen during this period. Three months ago, he was hospitalized for acute pancreatitis. He discharged himself against medical advice at that time. There is no family history of illness. He does not smoke. He drinks 2–3 beers and a pint of vodka daily. He has a history of using intravenous heroin. He has not had a stable job for a year. He is only oriented to place and person. His temperature is 37.1°C (98.8°F), pulse is 90/min, and blood pressure is 110/96 mm Hg. There is a carpopedal spasm while measuring his blood pressure. Cardiopulmonary examination shows no abnormalities. Deep tendon reflexes are 4+ bilaterally. Neurologic examination shows no focal findings. Which of the following is the most appropriate pharmacotherapy?? {'A': 'Sodium bicarbonate', 'B': 'Lorazepam', 'C': 'Magnesium sulfate', 'D': 'Fomepizole', 'E': 'Vitamin B1 (thiamine)\n"'},
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C: Magnesium sulfate
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Answer the following medical question with one of the provided options:
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Q:A 72-year-old woman is brought to the emergency department with dyspnea for 2 days. She is on regular hemodialysis at 3 sessions a week but missed her last session due to an unexpected trip. She has a history of congestive heart failure. After urgent hemodialysis, the patient’s dyspnea does not improve as expected. The cardiologist is consulted. After evaluation of the patient, he notes in the patient’s electronic record: “the patient does not have a chronic heart condition and a cardiac cause of dyspnea is unlikely.” The following morning, the nurse finds the cardiologist’s notes about the patient not having congestive heart failure odd. The patient had a clear history of congestive heart failure with an ejection fraction of 35%. After further investigation, the nurse realizes that the cardiologist evaluated the patient’s roommate. She is an elderly woman with a similar first name. She is also on chronic hemodialysis. To prevent similar future errors, the most appropriate strategy is to use which of the following?? {'A': 'A patient’s medical identification number at every encounter by any healthcare provider', 'B': 'A patient’s medical identification number at every physician-patient encounter', 'C': 'Two patient identifiers at every nurse-patient encounter', 'D': 'Two patient identifiers at every patient encounter by any healthcare provider', 'E': 'Two patient identifiers at every physician-patient encounter'},
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D: Two patient identifiers at every patient encounter by any healthcare provider
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Answer the following medical question with one of the provided options:
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Q:A 30-year-old woman presents to the emergency department in a state of confusion and disorientation that started this morning. She is accompanied by her husband who says that she has been unwell for about one week. She has been complaining of fatigue. Her husband says that this morning, she also complained that her urine was dark red in color and that there were some red spots over her legs. He did notice some changes in her level of consciousness that worsened over time and he decided to bring her in today. She does not have a significant medical history. Physical examination shows petechiae over her arms and legs. She is conscious but drowsy and disoriented and unable to answer the physician’s questions appropriately. Her temperature is 38.3°C (100.9°F), blood pressure is 160/100 mm Hg, pulse rate is 90/min, and respiratory rate is 20/min. Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 9,000/mm3 Platelet count 30,000/mm3 Bleeding time 10 min Prothrombin time 12 s Activated partial thromboplastin time 30 s D-dimer 0.4 mg/L (normal < 0.5 mg/L) Serum fibrinogen 350 mg/dL (normal 200–400 mg/dL) Serum bilirubin (indirect) 2.2 mg/dL Serum creatinine 1.5 mg/dL Serum LDH 1,010 U/L Based on her history, and her physical and laboratory findings, which of the following is the most likely pathophysiology for her presentation?? {'A': 'Systemic activation of blood coagulation', 'B': 'GPIIb/IIIa deficiency and failure of platelet aggregation', 'C': 'E. coli-mediated endothelial damage and formation of microthrombi', 'D': 'Decreased ADAMTS13 causing platelet adhesion and formation of microthrombi', 'E': 'Antiplatelet antibodies'},
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D: Decreased ADAMTS13 causing platelet adhesion and formation of microthrombi
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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 the clinic with a complaint of increasing shortness of breath for the past 2 years. His shortness of breath is associated with mild chest pain and occasional syncopal attacks during strenuous activity. There is no history of significant illness in the past, however, one of his uncles had similar symptoms when he was his age and died while playing basketball a few years later. He denies alcohol use, tobacco consumption, and the use of recreational drugs. On examination, pulse rate is 76/min and is regular and bounding; blood pressure is 130/70 mm Hg. A triple apical impulse is observed on the precordium and a systolic ejection crescendo-decrescendo murmur is audible between the apex and the left sternal border along with a prominent fourth heart sound. The physician then asks the patient to take a deep breath, close his mouth, and pinch his nose and try to breathe out without allowing his cheeks to bulge out. In doing so, the intensity of the murmur increases. Which of the following hemodynamic changes would be observed first during this maneuver?? {'A': '↓ Mean Arterial Pressure, ↑ Heart rate, ↑ Baroreceptor activity, ↓ Parasympathetic Outflow', 'B': '↑ Mean Arterial Pressure, ↓ Heart rate, ↓ Baroreceptor activity, ↑ Parasympathetic Outflow', 'C': '↑ Mean Arterial Pressure, ↑ Heart rate, ↓ Baroreceptor activity, ↓ Parasympathetic Outflow', 'D': '↓ Mean Arterial Pressure, ↑ Heart rate, ↓ Baroreceptor activity, ↓ Parasympathetic Outflow', 'E': '↑ Mean Arterial Pressure, ↓ Heart rate, ↑ Baroreceptor activity, ↑ Parasympathetic Outflow'},
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E: ↑ Mean Arterial Pressure, ↓ Heart rate, ↑ Baroreceptor activity, ↑ Parasympathetic Outflow
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Answer the following medical question with one of the provided options:
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Q:A 34-year-old woman comes to the physician a week after noticing a lump in her left breast. Three months ago, she was discharged from the hospital after treatment of multiple injuries sustained in a motor vehicle collision. Her only medication is an oral contraceptive. Her mother died of ovarian cancer. Examination shows a 2.5-cm, nontender mass in the upper outer quadrant of the left breast. Mammography shows a circumscribed radiolucent lesion with a rim of peripheral calcification. A photomicrograph of tissue from a biopsy of the mass is shown. Which of the following is the most likely cause of the breast swelling?? {'A': 'Thrombophlebitis of subcutaneous veins', 'B': 'Stimulation of estrogen receptors', 'C': 'Defect in DNA repair', 'D': 'Obstruction of lactiferous ducts', 'E': 'Release of cytoplasmic triglycerides'},
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E: Release of cytoplasmic triglycerides
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Answer the following medical question with one of the provided options:
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Q:A 24-year-old man comes to the physician because his vision has worsened rapidly over the last 2 months. His maternal uncle lost his vision suddenly over a period of 3 months at 26 years of age. The patient's wife and 1-year-old son have normal vision. Funduscopic examination of the patient shows bilateral circumpapillary telangiectasia. Genetic testing shows a missense mutation in one of the genes of the electron transport chain complexes. The probability that this patient's son will be affected by the same disease is closest to which of the following?? {'A': '0%', 'B': '25%', 'C': '33%', 'D': '50%', 'E': '100%'},
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A: 0%
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Answer the following medical question with one of the provided options:
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Q:A 6-month-old infant boy (neonate) is brought to the clinic for a check-up by a couple who recently adopted him from foster care. The biological mother was from a rehabilitation facility and was found incompetent to care for the child, hence he was handed over to foster care. No other information is available regarding his prenatal or birth history. On examination, his weight is found to be below the 3rd percentile. Physical appearance is remarkable for midfacial hypoplasia with a flattened nasal bridge, smooth philtrum, and thin lips. Auscultation reveals a grade 3/6 holosystolic murmur at the left lower sternal border. Developmental delay is noted as well. Which of the following teratogens is most likely to be associated with the neonate’s presentation?? {'A': 'Alcohol', 'B': 'Lithium', 'C': 'Phenytoin', 'D': 'Tobacco', 'E': 'Cocaine'},
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A: Alcohol
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Answer the following medical question with one of the provided options:
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Q:A 16-year-old girl is brought to the emergency department unresponsive. A witness reports that she became anxious, lightheaded, and began sweating and trembling a few minutes before she lost consciousness. Her vitals are as follows: blood pressure 95/60 mm Hg, heart rate 110/min, respiratory rate 21/min, and temperature 35.5°C (95.5°F). She becomes responsive but is still somnolent. She complains of dizziness and weakness. A more detailed history reveals that she has drastically restricted her diet to lose weight for the past 18 hours, and has not eaten today. Her skin is pale, wet, and cold. The rest of the physical examination is unremarkable. Blood testing shows a plasma glucose level of 2.8 mmol/L (50.5 mg/dL). Which of the following statements is true?? {'A': 'There is an increase in the glycogen synthesis rate in this patient’s hepatocytes.', 'B': 'The patient’s symptoms are most likely the consequence of increased insulin secretion from the pancreatic islets.', 'C': 'Hypoglycemia in this patient is being compensated with an increased glycogenolysis rate.', 'D': 'Epinephrine-induced gluconeogenesis is the main process that allows for the compensation of a decreased glucose level.', 'E': 'The patient’s hypoglycemia inhibits glucagon release from pancreatic alpha cells.'},
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C: Hypoglycemia in this patient is being compensated with an increased glycogenolysis rate.
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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 was brought in by his wife for progressively worsening memory and bizarre behavior over the past 2 months. The wife reports that he has been sleeping 15 hours a day, but is still complaining of fatigue. He frequently forgets important events such as his son’s graduation and left the stove running 2 days ago. During the encounter, the patient reports that “it is no longer worth living.” Past medical history is significant for a corneal transplant 7 years ago. Physical examination reveals depressed mood, healed surgical scar on the left neck, and sustained jerking of the left foot. Which of the following could have prevented this patient’s condition?? {'A': 'Antidepressant therapy', 'B': 'Early screening for depression', 'C': 'Good social and familial support system', 'D': 'Specific autoclave sterilization', 'E': 'Statin therapy'},
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D: Specific autoclave sterilization
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Answer the following medical question with one of the provided options:
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Q:A 9-year-old boy is brought to the pediatrician by his parents with a fever, cough, and cold symptoms that began 7 days ago. He has been complaining of right ear pain for the last 2 days. He is otherwise a completely healthy child with no known medical conditions. On physical examination, the temperature is 39.0°C (102.2°F), the pulse is 114 /min, the blood pressure is 106/74 mm Hg, and the respiratory rate is 26/min. On chest auscultation, rales are heard over the right subscapular region accompanied by bronchial breathing in the same region. Examination of the right external auditory canal reveals an erythematous, bulging tympanic membrane. The results of a complete blood count are as follows: Hemoglobin % 11 g/dL WBC count 12,000/mm3 Neutrophils 88% Lymphocytes 10% Monocytes 2% Platelet count 200,000/mm3 A chest radiograph shows a focal homogenous opacity in the right lung suggestive of consolidation. Bacteriologic cultures of the blood, nasopharynx, and sputum grew Moraxella catarrhalis. Which of the following is the antibiotic of choice?? {'A': 'Cefadroxil', 'B': 'Cephalexin', 'C': 'Doxycycline', 'D': 'Linezolid', 'E': 'Trimethoprim-sulfamethoxazole'},
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E: Trimethoprim-sulfamethoxazole
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Answer the following medical question with one of the provided options:
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Q:A 21-year-old nurse starts to feel ill during his evening shift. Earlier this evening, he started his shift in his normal state of health. Past medical history is significant for multiple admissions to the hospital under strange circumstances. One time he presented to the emergency department complaining of severe abdominal pain and gallstones, though no stones were identified and he was discharged after a full workup. Another time he was admitted for recurrent vomiting episodes and he was discharged after an EGD and several rounds of antiemetics. He has also visited an outpatient clinic for back pain and knee pain, though no findings were ever identified. He takes a multivitamin every day. His mother developed breast cancer at 47 and his father is healthy. Today, his blood pressure is 120/80 mm Hg, heart rate is 105/min, respiratory rate is 17/min, and temperature is 36.9°C (98.4°F). On physical exam, he appears thin and anxious. He is diaphoretic with clammy hands. His heart is tachycardic with an irregular rhythm and his lungs are clear to auscultation bilaterally. A urine toxicology test and EKG are negative. Random blood sugar is 45 mg/dL. The nurse is admitted and treated appropriately. After a thorough review of his medical records, the hospitalist assigned to this patient consults with psychiatry because she is concerned the patient may have factitious disorder. Which of the following would confirm a diagnosis of the factitious disorder in this patient?? {'A': 'Increased anion gap', 'B': 'Elevated troponin I and CK-MB levels', 'C': 'Normal c-peptide levels', 'D': 'Increased c-peptide levels', 'E': 'Presence of norepinephrine and vanillylmandelic acid in the urine'},
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C: Normal c-peptide levels
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Answer the following medical question with one of the provided options:
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Q:A 53-year-old man comes to the emergency department because of a 1-month history of cough productive of small amounts of blood-tinged sputum. During this time, he has also developed fatigue, myalgia, and shortness of breath on exertion. He has had a 4-lb (2-kg) weight loss over the past 2 months. He has no personal history of serious illness. His mother has systemic lupus erythematosus. His temperature is 37.2°C (99.0 °F), pulse is 98/min, respirations are 22/min, and blood pressure is 152/98 mm Hg. Diffuse rhonchi are heard on auscultation of the chest bilaterally. There are multiple palpable, erythematous, nonblanching lesions on the lower extremities bilaterally. Laboratory studies show: Leukocyte count 12,300 cells/mm3 Platelet count 400,000 cells/mm3 Erythrocyte sedimentation rate 83 mm/hr Serum Creatinine 2.1 mg/dL Antinuclear antibody 1:40 Urine Protein 3+ Blood 2+ RBC casts numerous A biopsy specimen of the skin shows inflammation of the arterioles and capillaries without granuloma formation. Further evaluation of this patient is most likely to show which of the following findings?"? {'A': 'Anti-glomerular basement membrane antibodies', 'B': 'Increased serum cryoglobulins', 'C': 'Anti-double stranded DNA antibodies', 'D': 'Myeloperoxidase antineutrophil cytoplasmic antibody', 'E': 'Hepatitis B surface antigen'},
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D: Myeloperoxidase antineutrophil cytoplasmic antibody
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Q:A 61-year-old male is given acetazolamide to treat open-angle glaucoma. Upon diuresis, his urine is found to be highly alkaline. Which of the following accounts for the alkaline nature of this patient’s urine?? {'A': 'Inhibition of chlorine reabsorption in the thick ascending loop of Henle', 'B': 'Inhibition of chlorine reabsorption in the distal convoluted tubule', 'C': 'Inhibition of acid secretion in alpha-intercalated cells', 'D': 'Inhibition of bicarbonate reabsorption in the proximal tubule', 'E': 'Inhibition of bicarbonate reabsorption in beta-intercalated cells'},
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D: Inhibition of bicarbonate reabsorption in the proximal tubule
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Q:A 45-year-old man is brought to the emergency department by ambulance after a motor vehicle collision. He is not responsive to verbal commands and is unable to provide any history. His pulse is 108/min and regular. Physical examination shows ecchymoses over the neck and back. Neurological examination indicates damage to the spinal cord at the level shown in the illustration. This patient's injury is most likely located at which of the following levels of the spinal cord?? {'A': 'L4', 'B': 'C2', 'C': 'S4', 'D': 'S2', 'E': 'T6'},
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E: T6
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Q:A 3-day-old girl is brought to the physician by her mother because of difficulty feeding and lethargy for 1 day. She had jaundice after birth and was scheduled for a follow-up visit the next day. Her hemoglobin is 18.5 g/dL, total bilirubin is 38.1 mg/dL, and direct bilirubin is 0.1 mg/dL. Despite appropriate measures, the infant dies. At autopsy, examination of the brain shows deep yellow staining of the basal ganglia and subthalamic nuclei bilaterally. Which of the following is the most likely cause of this infant's findings?? {'A': 'Defective intracellular bilirubin transport', 'B': 'Increased degradation of red blood cells', 'C': 'Extrahepatic obliteration of the biliary tree', 'D': 'Impaired glucuronidation of bilirubin', 'E': 'Decreased bilirubin uptake in hepatocytes'},
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D: Impaired glucuronidation of bilirubin
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Q:A 57-year-old man with a known angina pectoris starts to experience a severe burning retrosternal pain that radiates to his left hand. After 2 consecutive doses of sublingual nitroglycerin taken 5 minutes apart, there is no improvement in his symptoms, and the patient calls an ambulance. Emergency medical service arrives within 10 minutes and begins evaluation and prehospital management. The vital signs include: blood pressure 85/50 mm Hg, heart rate 96/min, respiratory rate 19/min, temperature 37.1℃ (98.9℉), and SpO2 89% on ambient air. Oxygen supply and intravenous access are established. An ECG shows the findings in the given image. Which of the following is a part of a proper further prehospital management strategy for this patient?? {'A': 'Administer aspirin 81 mg and transport to a percutaneous coronary intervention center', 'B': 'Perform pre-hospital thrombolysis and transport to a percutaneous coronary intervention center', 'C': 'Perform pre-hospital thrombolysis and transport to emergency department irrespective of percutaneous coronary intervention center presence', 'D': 'Administer aspirin 325 mg and transport to percutaneous coronary intervention center', 'E': 'Administer nitroglycerin and transport to percutaneous coronary intervention center'},
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D: Administer aspirin 325 mg and transport to percutaneous coronary intervention center
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Q:A 30-year-old woman who is 24-weeks pregnant presents to the emergency department with fever, painful urination, and headache. The patient's blood pressure is 111/67 mm Hg, the pulse is 95/min, the respiratory rate is 16/min, and the temperature is 38.3°C (101.1°F). Physical examination reveals bilateral tender inguinal lymphadenopathy and painful genital lesions. On closer inspection, the patient’s genital lesions contain clear fluid and measure 5–6 mm in diameter. What is the appropriate description of these lesions?? {'A': 'Ulcer', 'B': 'Pustule', 'C': 'Vesicle', 'D': 'Papule', 'E': 'Bulla'},
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C: Vesicle
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Q:An 8-year-old boy is brought to the emergency department because of shortness of breath and dry cough for 2 days. His symptoms began after he helped his father clean the basement. He is allergic to shellfish. Respirations are 26/min. Physical examination shows diffuse end-expiratory wheezing and decreased inspiratory-to-expiratory ratio. This patient's symptoms are most likely being caused by inflammation of which of the following structures?? {'A': 'Pleural cavity', 'B': 'Alveoli', 'C': 'Respiratory bronchioles', 'D': 'Distal trachea', 'E': 'Terminal bronchioles'},
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E: Terminal bronchioles
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Q:A 20-year-old man presents to the doctor's office for advice on improving his health. He admits to eating mostly junk food, and he knows that he should lose some weight. His daily physical activity is limited to walking around the college campus between classes. Except for an occasional headache for which he takes acetaminophen, he has no health concerns and takes no other medications. He denies smoking and illicit drug use, but admits to occasional beer binge drinking on weekends. He is sexually active with his current girlfriend and regularly uses condoms. His mother has type 2 diabetes mellitus and obesity, while his father has hypertension and hypercholesterolemia. The pulse is 74/min, the respiratory rate is 16/min, and the blood pressure is 130/76 mm Hg. The body mass index (BMI) is 29 kg/m2. Physical examination reveals an overweight young male, and the rest is otherwise unremarkable. The routine lab test results are as follows: Serum Glucose (fasting) 100 mg/dL Serum Electrolytes: Sodium 141 mEq/L Potassium 4.0 mEq/L Chloride 100 mEq/L Cholesterol, total 190 mg/dL HDL-cholesterol 42 mg/dL LDL-cholesterol 70 mg/dL Triglycerides 184 mg/dL Urinalysis: Glucose Negative Ketones Negative Leukocytes Negative Nitrites Negative RBCs Negative Casts Negative Which of the following lifestyle changes would most likely benefit this patient the most?? {'A': 'Weight reduction', 'B': 'Increasing dietary fiber', 'C': 'Increasing daily water intake', 'D': 'A low sodium diet', 'E': 'Starting a multivitamin'},
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A: Weight reduction
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Q:A 64-year-old man presents to the emergency department with sudden onset of chest pain and an episode of vomiting. He also complains of ongoing nausea and heavy sweating (diaphoresis). He denies having experienced such symptoms before and is quite upset. Medical history is significant for hypertension and types 2 diabetes mellitus. He currently smokes and has smoked at least half a pack daily for the last 40 years. Vitals show a blood pressure of 80/50 mm Hg, pulse of 50/min, respirations of 20/min, temperature of 37.2°C (98.9°F), and oximetry is 99% before oxygen by facemask. Except for the patient being visibly distressed and diaphoretic, the examination is unremarkable. ECG findings are shown in the picture. Where is the most likely obstruction in this patient’s cardiac blood supply? ? {'A': 'Right coronary artery', 'B': 'Left anterior descending artery', 'C': 'Left circumflex artery', 'D': 'Left main coronary artery', 'E': 'There is no obstruction'},
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A: Right coronary artery
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Q:A 3400-g (7 lb 8 oz) female newborn is delivered at 40 weeks' gestation. Physical examination shows pale skin, blonde hair, and blue irides. Her parents are from Haiti and express concern regarding the newborn's appearance. The most likely cause of this newborn's condition is a defect in which of the following processes?? {'A': 'Intracellular transport of melanosomes', 'B': 'Oxidation of dihydroxyphenylalanine', 'C': 'Glycosylation of procollagen', 'D': 'Transfer of melanosomes to keratinocytes', 'E': 'Migration of neural crest cell derivates'},
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B: Oxidation of dihydroxyphenylalanine
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Q:A 48-year-old woman with a known past medical history significant for hypertension presents for a second opinion of a left breast lesion. The lesions were characterized as eczema by the patient’s primary care physician and improved briefly after a trial of topical steroids. However, the patient is concerned that the lesions have started to grow. On physical examinations, there is an erythematous, scaly lesion involving the left breast nipple-areolar complex with weeping drainage. What is the next step in the patient’s management?? {'A': 'Bilateral breast ultrasound', 'B': 'Punch biopsy of the nipple, followed by bilateral mammography', 'C': 'Maintain regular annual mammography appointment', 'D': 'Oral corticosteroids', 'E': 'Left breast MRI'},
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B: Punch biopsy of the nipple, followed by bilateral mammography
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Q:A 27-year-old man comes to the physician with his wife because they have been unable to conceive. They have had regular unprotected sex for the past 18 months without using contraception. His wife has been tested and is fertile. The patient began puberty at the age of 13 years. He has been healthy except for an infection with Chlamydia trachomatis 10 years ago, which was treated with azithromycin. He is a professional cyclist and trains every day for 3–4 hours. His wife reports that her husband has often been stressed since he started to prepare for the national championships a year ago and is very conscious about his diet. His temperature is 36.5°C (97.7°F), pulse is 50/min, and blood pressure is 154/92 mm Hg. Physical examination of the husband shows an athletic stature with uniform inflammatory papular eruptions of the face, back, and chest. Genital examination shows small testes. Which of the following is the most likely underlying cause of this patient's infertility?? {'A': 'Anabolic steroid use', 'B': 'Heat from friction', 'C': 'Anorexia nervosa', 'D': 'Psychogenic erectile dysfunction', 'E': 'Kallmann syndrome\n"'},
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A: Anabolic steroid use
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Q:A 38-year-old woman presents with fever and acute onset chest pain for the past 12 hours. She describes the pain as severe, sharp and stabbing in character, and localized to the retrosternal area. She also says the pain is worse when she breathes deeply or coughs. Past medical history is significant for recently diagnosed systemic lupus erythematosus (SLE). Her vital signs include: blood pressure 110/75 mm Hg, pulse 95/min, and temperature 38.0°C (100.4°F). Physical examination is significant for a friction rub heard best at the lower left sternal border. Which of the following is the most likely diagnosis in this patient?? {'A': 'Serous pericarditis', 'B': 'Pericardial tamponade', 'C': 'Septic shock', 'D': 'Acute myocardial infarction', 'E': 'Constrictive pericarditis'},
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A: Serous pericarditis
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Q:A previously healthy 64-year-old man comes to the physician 3 days after noticing a lump in his right groin while he was bathing. He has no history of trauma to the region. He has hypercholesterolemia and hypertension treated with atorvastatin and labetalol. He has smoked 2 packs of cigarettes daily for 35 years. His vital signs are within normal limits. Examination shows a 4-cm (1.6-in), nontender, pulsatile mass with a palpable thrill at the right midinguinal point. On auscultation, a harsh continuous murmur is heard over the mass. Femoral and pedal pulses are palpable bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?? {'A': 'Femoral hernia', 'B': 'Femoral lymphadenopathy', 'C': 'Arteriovenous fistula of the femoral vessels', 'D': 'Femoral abscess', 'E': 'Femoral artery aneurysm'},
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E: Femoral artery aneurysm
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Q:A 3-month-old boy is brought to the physician by his parents because of a 2-day history of poor feeding and lethargy. He was born at term and has had three episodes of bilateral otitis media since birth. Umbilical cord separation occurred at the age of 8 weeks. He is at the 30th percentile for height and 20th percentile for weight. His temperature is 39°C (102.2°F) and blood pressure is 58/36 mm Hg. Physical examination shows white oral patches and confluent scaly erythematous skin lesions in the groin. Laboratory studies show a leukocyte count of 41,300/mm3 (92% segmented neutrophils and 8% lymphocytes) and a platelet count of 224,000/mm3. Blood cultures at 20°C (68°F) grow catalase-positive yeast cells that form pseudohyphae. Which of the following is the most likely underlying cause of this patient's symptoms?? {'A': 'Defective beta-2 integrin', 'B': 'Defective IL-2R gamma chain', 'C': 'Defective tyrosine kinase', 'D': 'Defective microtubules', 'E': 'Defective actin cytoskeleton'},
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A: Defective beta-2 integrin
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Q:A 37‐year‐old woman presents with a severe, deep, sharp pain in her right hand and forearm. A week before she presented her pain symptoms, she fell on her right forearm and developed mild bruising. She has type-1 diabetes mellitus and is on an insulin treatment. The physical examination reveals that her right hand and forearm were warmer, more swollen, and had a more reddish appearance than the left side. She feels an intense pain upon light touching of her right hand and forearm. Her radial and brachial pulses are palpable. The neurological examination is otherwise normal. The laboratory test results are as follows: Hemoglobin 15.2 g/dL White blood cell count 6,700 cells/cm3 Platelets 300,000 cells/cm3 Alanine aminotransferase 32 units/L Aspartate aminotransferase 38 units/L C-reactive protein 0.4 mg/L Erythrocyte sedimentation rate 7 mm/1st hour The X-ray of the right hand and forearm do not show a fracture. The nerve conduction studies are also within normal limits. What is the most likely diagnosis?? {'A': 'Cellulitis', 'B': 'Compartment syndrome', 'C': 'Complex regional pain syndrome', 'D': 'Diabetic neuropathy', 'E': 'Limb ischemia'},
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C: Complex regional pain syndrome
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Q:A 55-year-old man with a history of repeated hospitalization for chronic pancreatitis comes to the physician because of difficulty walking and standing steadily. Neurological examination shows an unsteady, broad-based gait, distal muscle weakness, decreased deep tendon reflexes, and an abnormal Romberg test. His hemoglobin concentration is 11.9 g/dL, mean corpuscular volume is 89/μm3, and serum lactate dehydrogenase is 105 U/L. His serum haptoglobin is slightly decreased. A deficiency of which of the following substances is the most likely cause of this patient's findings?? {'A': 'Tocopherol', 'B': 'Folate', 'C': 'Pyridoxine', 'D': 'Niacin', 'E': 'Phytomenadione'},
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A: Tocopherol
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Q:An 18-year-old man is brought to the emergency department 30 minutes after being stabbed in the chest during a fight. He has no other injuries. His pulse is 120/min, blood pressure is 90/60 mm Hg, and respirations are 22/min. Examination shows a 4-cm deep, straight stab wound in the 4th intercostal space 2 cm medial to the right midclavicular line. The knife most likely passed through which of the following structures?? {'A': 'Pectoral fascia, transversus thoracis muscle, right lung', 'B': 'Intercostal muscles, internal thoracic artery, right heart', 'C': 'Serratus anterior muscle, pleura, inferior vena cava', 'D': 'External oblique muscle, superior epigastric artery, azygos vein', 'E': 'Pectoralis minor muscle, dome of the diaphragm, right lobe of the liver'},
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A: Pectoral fascia, transversus thoracis muscle, right lung
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Q:A 42-year-old man comes to the physician because of a 6-month history of progressively worsening shortness of breath with exertion. He was diagnosed with systemic sclerosis 5 years ago. Vital signs are within normal limits. Physical examination shows puffy, taut skin over the fingers. Pulmonary examination is unremarkable. There is no jugular venous distention. An x-ray of the chest shows enlargement of the pulmonary vessels and a prominent right heart border. Cardiac catheterization shows elevated right ventricular pressures and a mean pulmonary artery pressure of 55 mm Hg. Treatment with tadalafil is begun. The expected beneficial effect of this drug is most likely due to which of the following actions?? {'A': 'Blockade of endothelin-1 binding at the endothelin receptor', 'B': 'Decreased smooth muscle sensitivity to norepinephrine', 'C': 'Increased activation of protein kinase A', 'D': 'Reduced transmembrane calcium current', 'E': 'Enhanced activity of nitric oxide'},
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E: Enhanced activity of nitric oxide
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Q:A 20-year-old male presents to the emergency department because of several days of back pain and fatigue. He is a college student who just returned from a study abroad program in Morocco. During his final week abroad he engaged in a number of recreational activities including swimming at the beach, eating local foods such as couscous and bean salad, and riding a camel into the desert. His temperature is 99°F (37°C), blood pressure is 121/79 mmHg, pulse is 70/min, and respirations are 11/min. He says that otherwise he has been healthy except for some episodes of dark urine. Upon physical exam, his skin is found to be more yellow than usual under his eyelids. Which of the following findings would most likely be seen in this patient?? {'A': 'Absent urine bilirubin', 'B': 'Elevated urine bilirubin', 'C': 'Decreased urine urobilinogen', 'D': 'Conjugated hyperbilirubinemia', 'E': 'Elevated aspartate aminotransferase'},
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A: Absent urine bilirubin
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Q:A 40-year-old man presents with acute abdominal pain. Past medical history is significant for hepatitis C, complicated by multiple recent visits with associated ascites. His temperature is 38.3°C (100.9°F), heart rate is 115/min, blood pressure is 88/48 mm Hg, and respiratory rate is 16/min. On physical examination, the patient is alert and in moderate discomfort. Cardiopulmonary examination is unremarkable. Abdominal examination reveals distant bowel sounds on auscultation. There is also mild diffuse abdominal tenderness to palpation with guarding present. The remainder of the physical examination is unremarkable. A paracentesis is performed. Laboratory results are significant for the following: Leukocyte count 11,630/µL (with 94% neutrophils) Platelets 24,000/µL Hematocrit 29% Ascitic fluid analysis: Cell count 658 PMNs/µL Total protein 1.2 g/dL Glucose 24 mg/dL Gram stain Gram-negative rods Culture Culture yields growth of E. coli Which of the following is the next, best step in the management of this patient?? {'A': 'Surgical consultation', 'B': 'Intravenous fluid resuscitation', 'C': 'Intravenous cefotaxime', 'D': 'Serum lipase level', 'E': 'Abdominal radiography and contrast CT of the abdomen'},
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C: Intravenous cefotaxime
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Q:A 78-year-old woman is accompanied by her family for a routine visit to her primary care provider. The family states that 5 months prior, the patient had a stroke and is currently undergoing physical therapy. Today, her temperature is 98.2°F (36.8°C), blood pressure is 112/72 mmHg, pulse is 64/min, and respirations are 12/min. On exam, she is alert and oriented with no deficits in speech. Additionally, her strength and sensation are symmetric and preserved bilaterally. However, on further neurologic testing, she appears to have some difficulty with balance and a propensity to fall to her right side. Which of the following deficits does the patient also likely have?? {'A': 'Contralateral eye deviation', 'B': 'Hemiballismus', 'C': 'Hemispatial neglect', 'D': 'Intention tremor', 'E': 'Truncal ataxia'},
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D: Intention tremor
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Q:A 72-year-old man presents to the primary care clinic for evaluation of progressive fatigue and weight loss. His past medical history is significant for hypercholesterolemia, type 2 diabetes mellitus, aortic stenosis, and chronic renal insufficiency. He endorses being well-rested after waking from sleep but fatiguing rapidly during the day. In addition, he states that he has lost 15lbs over the previous month. His temperature is 98.3°F (36.8°C), pulse is 100/min, blood pressure is 110/85 mmHg, respirations are 16/min, and oxygen saturation is 96% on room air. Physical exam is notable for conjunctival pallor and scattered areas of ecchymoses. His laboratory results are shown below: Serum: Na+: 140 mEq/L K+: 4.0 mEq/L Cl-: 101 mEq/L HCO3-: 22 mEq/L BUN: 30 mg/dL Glucose: 160 mg/dL Creatinine: 1.9 mg/dL Leukocyte count: 1,100/mm^3 Absolute neutrophil count 920/mm^3 Hemoglobin 8.4 g/dL Platelet count: 45,000/mm^3 Mean corpuscular hemoglobin concentration: 34% Red blood cell distribution width: 12.0% Mean corpuscular volume: 92 µm^3 Lactate dehydrogenase: 456 IU/L Haptoglobin 120 mg/dL Fibrinogen 214 mg/dL A bone marrow biopsy is performed which shows cells that are CD19+, CD20+, CD11c+, and stain with acid phosphatase 5 and tartrate-resistant. Which of the following is the next best step in the treatment of his disorder?? {'A': 'Hydroxyurea', 'B': 'Cladribine', 'C': 'Filgrastim', 'D': 'Doxorubicin', 'E': 'Cyclophosphamide'},
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B: Cladribine
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Q:A 21-year-old female presents to her first gynecology visit. She states that six months ago, she tried to have sexual intercourse but experienced severe pain in her genital region when penetration was attempted. This has continued until now, and she has been unable to have intercourse with her partner. The pain is not present at any other times aside from attempts at penetration. The patient is distressed that she will never be able to have sex, even though she wishes to do so. She does not recall ever having a urinary tract infection and has never been sexually active due to her religious upbringing. In addition, she has never tried to use tampons or had a Pap smear before. She denies alcohol, illicit drugs, and smoking. The patient is 5 feet 6 inches and weighs 146 pounds (BMI 23.6 kg/m^2). On pelvic exam, there are no vulvar skin changes, signs of atrophy, or evidence of abnormal discharge. The hymen is not intact. Placement of a lubricated speculum at the introitus elicits intense pain and further exam is deferred for patient comfort. Office urinalysis is negative. Which of the following is a risk factor for this patient’s condition?? {'A': 'Low estrogen state', 'B': 'Endometriosis', 'C': 'Generalized anxiety disorder', 'D': 'Squamous cell carcinoma of the vulva', 'E': 'Body dysmorphic disorder'},
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C: Generalized anxiety disorder
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Q:A 52-year-old man presents to the emergency department because of fatigue, abdominal distension, and swelling of both legs for the last 3 weeks. His wife says that he lost some weight recently. He has had type 2 diabetes mellitus for 12 years, for which he takes metformin and sitagliptin. He has a history of Hodgkin’s lymphoma which was successfully treated with mediastinal radiation 20 years ago. He does not smoke or drink alcohol. He has a family history of type 2 diabetes in his father and elder sister. Vital signs include a blood pressure of 100/70 mm Hg, a temperature of 36.9°C (98.4°F), and a regular radial pulse of 90/min. On physical examination, there is jugular venous distension, most prominently when the patient inhales. Bilateral ankle pitting edema is present, and his abdomen is distended with shifting dullness on percussion. An early diastolic knocking sound is audible on the chest. His chest X-ray is shown in the exhibit. Which of the following is the best treatment for this patient?? {'A': 'Pericardiocentesis', 'B': 'Ibuprofen, plus colchicine', 'C': 'Pericardiectomy', 'D': 'Pleurodesis', 'E': 'Percutaneous aspiration with high-flow oxygen'},
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C: Pericardiectomy
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Q:A 20-year-old man is brought to the emergency department for evaluation of an animal bite. He was hiking earlier that day when he was bitten by a raccoon. He says the attack was unprovoked and the animal ran away after the encounter. He was bitten by a stray dog when he was 11 years old and received postexposure prophylaxis for rabies at that time. His immunizations are up-to-date. His immunization record shows he received 3 doses of diphtheria-tetanus-acellular pertussis vaccine as a child and a tetanus-diphtheria-acellular pertussis vaccination at the age of 16. He is in no apparent distress. His temperature is 98.4°F (36.9°C), pulse is 72/min, respirations are 18/min, and blood pressure is 124/75 mm Hg. He has a wound on his left lower extremity with actively bleeding puncture sites. The wound is thoroughly irrigated with normal saline and cleansed with antiseptic and a bandage is applied. Which of the following is the most appropriate next step in management?? {'A': 'No action needed', 'B': 'Tetanus booster, rabies immunoglobulin', 'C': 'Rabies immunoglobulin and vaccine', 'D': 'Tetanus booster', 'E': 'Rabies vaccination'},
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E: Rabies vaccination
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Q:A 35-year-old woman with no significant past medical history is brought in by ambulance after a major motor vehicle collision. Temperature is 97.8 deg F (36.5 deg C), blood pressure is 76/40, pulse is 110/min, and respirations are 12/min. She arouses to painful stimuli and makes incomprehensible sounds, but is unable to answer questions. Her abdomen is distended and diffusely tender to palpation. Bedside ultrasound shows blood in the peritoneal cavity. Her husband rushes to the bedside and states she is a Jehovah’s Witness and will refuse blood products. No documentation of blood refusal is available for the patient. What is the most appropriate next step in management?? {'A': 'Attempt to contact the patient’s parents for additional collateral information', 'B': 'Consult the hospital ethics committee', 'C': 'Observe and reassess mental status in an hour to see if patient can consent for herself', 'D': 'Administer blood products', 'E': "In accordance with the husband's wishes, do not transfuse any blood products"},
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D: Administer blood products
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Q:A 22-year-old man comes to the physician for a routine physical examination. He feels well. He has no history of major medical illness and takes no medications. His vital signs are within normal limits. Examination shows no abnormalities. Laboratory studies, including a complete blood count and a standard electrolyte panel, are within normal limits. Urine dipstick is negative for glucose; a reducing substance test result of the urine is positive. Which of the following is the most appropriate dietary recommendation for this patient?? {'A': 'Eliminate fructose and sucrose', 'B': 'Decrease purine intake', 'C': 'No changes needed', 'D': 'Eliminate galactose and lactose', 'E': 'Increase intake of ketogenic amino acids'},
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C: No changes needed
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Q:A 24-year-old woman, G1P0, presents to her OB/GYN for her annual examination with complaints of painful cramps, abdominal pressure, and bloating with her cycle. She reports that she has not menstruated since her missed abortion requiring dilatation and curettage (D&C) seven months ago. She is sexually active with her husband and is not using any form of contraception. Her BMI is 29. At the clinic, her vitals are as follows: temperature, 98.9°F; pulse, 80/min; and blood pressure, 120/70 mm Hg. The physical examination is unremarkable. Thyroid-stimulating hormone, follicle-stimulating hormone, and prolactin concentrations are all within normal limits. The patient tests negative for qualitative serum beta‐hCG. A progestin challenge test reveals no withdrawal bleeding. What is the most likely diagnosis?? {'A': 'Ectopic pregnancy', 'B': 'Pelvic inflammatory disease', 'C': 'Endometriosis', 'D': 'Asherman syndrome', 'E': 'Hypothalamic hypoestrogenism'},
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D: Asherman syndrome
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Q:A 62-year-old woman presents to the clinic for postmenopausal bleeding for the past month. She reports that the bleeding often occurs after intercourse with her husband. The patient denies fever, weight loss, chills, chest pain, abdominal pain, or shortness of breath but endorses mild dyspareunia and vaginal discharge. Her past medical history is significant for human papilloma virus and cervical cancer that was treated with surgical resection and radiation 5 years ago. Physical examination is unremarkable except for an irregular mass protruding from the vaginal wall. What is the most likely explanation for this patient’s condition?? {'A': 'Atrophy of vaginal tissues secondary to old age', 'B': 'Metastasis of cervical cancer via direct extension', 'C': 'Metastasis of cervical cancer via hematogenous spread', 'D': 'Primary malignancy of vaginal squamous cells', 'E': 'Primary malignancy of endometrial cells'},
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B: Metastasis of cervical cancer via direct extension
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Q:A 69-year-old man with type 2 diabetes mellitus comes to the physician for a follow-up examination. His only medication is metformin. He has tried to lose weight for several years without success. He is 168 cm (5 ft 6 in) tall and weighs 110 kg (243 lb); BMI is 39 kg/m2. His hemoglobin A1c is 8.5%. Which of the following is the most appropriate antidiabetic drug to address both this patient's glucose control and weight?? {'A': 'Miglitol', 'B': 'Glipizide', 'C': 'Liraglutide', 'D': 'Nateglinide', 'E': 'Rosiglitazone'},
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C: Liraglutide
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Q:A 52-year-old man presents to the emergency department (ED) complaining of palpitations and lightheadedness for the last 30 minutes. He denies feeling pain or discomfort in his chest and is not short of breath. He does not have any known medical problems and does not take any medications regularly. He drinks 4–6 caffeinated drinks a day. The temperature is 36.8°C (98.2°F), the pulse rate is 150/min and slightly irregular, the blood pressure is 144/84 mm Hg, and the respiratory rate is 16/min. A focused examination of the cardiovascular and respiratory systems is unremarkable. An electrocardiogram is performed in the ED and the results are shown in the accompanying image. The ED physician prescribes a calcium channel blocking agent for his condition. Which of the following statements best describes the choice of verapamil over nifedipine in the treatment of this patient?? {'A': 'Verapamil slows atrioventricular conduction more effectively than nifedipine.', 'B': 'Verapamil has fewer negative inotropic effects than nifedipine.', 'C': 'Verapamil does not have non-specific anti-adrenergic effects, unlike nifedipine.', 'D': 'Verapamil is more effective in decreasing blood pressure than nifedipine.', 'E': 'Verapamil binds to the α2 subunit of the L-type calcium channel, while nifedipine binds to the α1 subunit of the L-type calcium channel.'},
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A: Verapamil slows atrioventricular conduction more effectively than nifedipine.
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Q:A 65-year-old woman is brought to the emergency room by her family with complaints of confusion and change in behavior. Her family states that over the last 2 weeks, the patient has become increasingly irritable and confusion as well as aggressive toward strangers. In addition to her altered mental status, her family also endorses recent episodes of abdominal pain and watery diarrhea. Her medications include HCTZ, enalapril, loperamide, and a calcium supplement. There is no history of recent travel outside the United States. Her temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 93% on room air. Physical exam is notable for a thin, ill-appearing woman. Cardiac exam is significant for sinus tachycardia and bowel sounds are hyperactive. Purple discoloration with scale-crust is noted around her neck and upper chest, as well as on her hands and feet. A chest radiograph shows clear lung fields bilaterally, but an echocardiogram shows thickening of the right ventricular endocardium with mild tricuspid stenosis. Which of the following is the next best diagnostic step?? {'A': 'Stool culture', 'B': 'Anti-nuclear antibody titer', 'C': 'CT scan of the head', 'D': 'CT scan of the abdomen', 'E': 'Serum 5-hydroxyindoleacetic acid levels'},
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E: Serum 5-hydroxyindoleacetic acid levels
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Q:A 2-day-old boy is evaluated in the nursery for minimal movement in his left upper limb. He was born at 41 weeks gestation by an assisted forceps-vaginal delivery to a 42-year-old obese woman. Birth weight was 4.4 kg (9.7 lb). The mother had 4 previous vaginal deliveries, all requiring forceps. Examinations of the left upper limb show that the arm hangs by his side and is rotated medially. His forearm is extended and pronated, and his wrist and fingers are flexed. Moro reflex is present only on the right side. Which of the following muscles was spared from the injury sustained during delivery?? {'A': 'Deltoid', 'B': 'Biceps', 'C': 'Triceps', 'D': 'Supraspinatus', 'E': 'Infraspinatus'},
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C: Triceps
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Q:In an experimental model, a compound is centrally administered to mice. Following administration, the mice display increased desire for food and increased appetite. The administered compound is most likely similar to which of the following?? {'A': 'Leptin', 'B': 'Neuropeptide-Y', 'C': 'Peptide YY', 'D': 'Glucagon-like peptide 1', 'E': 'Cholecystokinin'},
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B: Neuropeptide-Y
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Q:A 30-year-old man presents to your clinic complaining of excessive thirst and frequent urination for the past few months. Urine testing reveals a low urine osmolarity, which fails to increase after subjecting the patient to a water deprivation test and injection of desmopressin. Further into the encounter, the patient reveals that he has been on a mood stabilizer for bipolar disorder for several years. Which of the following is the most likely cause of his polyuria?? {'A': 'Central diabetes insipidus', 'B': 'Nephrogenic diabetes insipidus', 'C': 'Primary polydipsia', 'D': 'Syndrome of inappropriate ADH secretion', 'E': 'Urinary tract infection'},
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B: Nephrogenic diabetes insipidus
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Q:A 28-year-old woman, gravida 1, para 0, at 32 weeks' gestation is evaluated for vaginal bleeding. Five days ago, she was admitted to the hospital and started on treatment for a deep vein thrombosis in the right leg. Her pulse is 125/min and blood pressure is 95/67 mm Hg. Physical examination shows large hematomas on the upper limbs and swelling in the right calf. There is a large amount of bright red blood in the vaginal vault. Laboratory studies show a hemoglobin of 8.9 mg/dL, platelet count of 185,000/mm3, and activated partial thromboplastin time of 160 seconds. Which of the following is the most appropriate pharmacotherapy to rapidly reverse this patient's coagulopathy?? {'A': 'Protamine sulfate', 'B': 'Prothrombin complex concentrate', 'C': 'Vitamin K', 'D': 'Alteplase', 'E': 'Fresh frozen plasma'},
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A: Protamine sulfate
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Q:A 2-week old newborn is brought to the physician for a follow-up examination after the initial newborn examination showed asymmetry of the legs. She was born at term to a 26-year-old woman, gravida 3, para 2. Pregnancy was complicated by a breech presentation and treated with an emergency lower segment transverse cesarean section. The newborn's head circumference is 35 cm (13.7 in). She is at the 60th percentile for length and 75th percentile for weight. Cardiac examination shows no abnormalities. The spine is normal. Abduction of the right hip after cupping the pelvis and flexing the right hip and knee causes a palpable clunk. The feet have no deformities. Ultrasonography of the hip determines the angle between lines along the bone acetabulum and the ilium is 50°. Which of the following is the most appropriate next step in management?? {'A': 'Reassure the mother and schedule follow-up appointment in 4 weeks', 'B': 'Immobilize the hips with a spica cast', 'C': 'Perform closed reduction of the right hip', 'D': 'Obtain an MRI of the right hip', 'E': 'Treat using a harness'},
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E: Treat using a harness
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Q:A 29-year-old man presents to his primary care provider complaining of not being able to get enough rest at night. He goes to bed early enough and has otherwise good sleep hygiene but feels drained the next day. He feels he is unable to perform optimally at work, but he is still a valued employee and able to complete his share of the work. About a month ago his wife of 5 years asked for a divorce and quickly moved out. He has cut out coffee after 12 pm and stopped drinking alcohol. He also exercises 3 days per week. Today, his blood pressure is 120/80 mm Hg, heart rate is 95/min, respiratory rate is 25/min, and temperature is 37.0°C (98.6°F ). On physical exam, his heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. A CMP, CBC, and thyroid test are negative. Which of the following statements best describes this patient’s condition?? {'A': 'Symptoms will wax and wane but may persist for 6-12 months', 'B': 'Mild cognitive impairment can last up to 6 months', 'C': 'Symptoms are persistent and must resolve within 6 months of the stressor terminating', 'D': 'Symptoms develop within 3 months of the stressor', 'E': 'Symptoms are usually self-limited and may persist for 2 years'},
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A: Symptoms will wax and wane but may persist for 6-12 months
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Q:A 27-year-old man visits the office with complaints of pain in his lower limb muscles and joints. He cannot remember exactly when it started, but it intensified after his recent hiking trip. He is a hiking enthusiast and mentions having gone on a recent trekking expedition in Connecticut. He does not recall any particular symptoms after the hike except for a rash on his left calf with distinct borders (image provided in the exhibit). The patient does not complain of fever, chills or any changes in his vision. His vital signs show a blood pressure of 120/70 mm Hg, a pulse of 97/min, and respirations of 18/min. There is tenderness in his left calf with a decreased range of motion in the left knee joint. No joint effusions are noted. Which of the following would be the next best step in the management of this patient?? {'A': 'Serological testing', 'B': 'Blood culture', 'C': 'Start doxycycline therapy', 'D': 'Ask him to come back after one week', 'E': 'Start erythromycin therapy'},
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C: Start doxycycline therapy
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Q:A 30-year-old man is brought to the emergency department by his brother for the evaluation of progressive confusion over the past 6 hours. The patient is lethargic and unable to answer questions. His brother states that there is no personal or family history of serious illness. His temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure 135/80 mm Hg. Physical examination shows warm, dry skin and dry mucous membranes. The pupils are dilated. The abdomen is distended and bowel sounds are hypoactive. Laboratory studies are within normal limits. An ECG shows no abnormalities. Intoxication with which of the following substances is the most likely cause of this patient's symptoms?? {'A': 'Cannabis', 'B': 'Opioid', 'C': 'Amphetamine', 'D': 'Carbon monoxide', 'E': 'Antihistamine\n"'},
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E: Antihistamine "
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Q:A 12-year-old boy, otherwise healthy, presents with frequent nosebleeds and lower extremity bruising. His mother reports that his symptoms started about 2 weeks ago and have not improved. The patient received the Tdap vaccine 2 weeks ago. He has no current medications. The review of systems is significant for the patient having a stomach ache after winning a hamburger eating competition 2 weeks ago. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 110/75 mm Hg, pulse 95/min, respirations 15/min, and oxygen saturation 99% on room air. On physical exam, the patient is alert and cooperative. The cardiac exam is normal. The lungs are clear to auscultation bilaterally. The lower extremities findings are shown in the image. Laboratory results are pending. Which of the following best describes the pathogenesis of this patient’s condition?? {'A': 'Shiga-toxin mediated damage to vascular endothelium, resulting in microthrombi formation', 'B': 'Deficiency of ADAMTS13', 'C': 'IgG autoantibodies against platelet glycoproteins', 'D': 'Systemic activation of clotting cascade resulting in platelet and coagulation factor consumption', 'E': 'Deposition of IgA immune complexes'},
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C: IgG autoantibodies against platelet glycoproteins
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Q:A 67-year-old male with a past medical history of diabetes type II, obesity, and hyperlipidemia presents to the general medical clinic with bilateral hearing loss. He also reports new onset vertigo and ataxia. The symptoms started a day after undergoing an uncomplicated cholecystectomy. If a drug given prophylactically just prior to surgery has caused this patient’s symptoms, what is the mechanism of action of the drug?? {'A': 'Inhibition of the formation of the translation initiation complex', 'B': 'Inhibition of DNA-dependent RNA polymerase', 'C': 'Inhibition of cell wall synthesis', 'D': 'Inhibition of DNA gyrase', 'E': 'Formation of free radical toxic metabolites that damage DNA'},
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A: Inhibition of the formation of the translation initiation complex
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Q:A 72-year-old female is brought to the emergency department by ambulance because she was unable to walk. She says that she cut her leg while falling about a week ago. Since then, the wound has started draining fluid and become progressively more painful. She is found to have necrotizing fasciitis and is taken emergently to the operating room. Histological examination of cells along the fascial planes reveal cells undergoing necrosis. Which of the following represents the earliest sign that a cell has progressed to irreversible damage in this patient?? {'A': 'Chromatin dissolution and disappearance', 'B': 'Condensation of DNA into a basophilic mass', 'C': 'Fragmentation of the nucleus', 'D': 'Membrane blebbing from organelles', 'E': 'Ribosomal detachment from the endoplasmic reticulum'},
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B: Condensation of DNA into a basophilic mass
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Q:A 12-year-old boy is brought to the physician because of fever, malaise, and a painful, itchy rash on the right shoulder for 2 weeks. The patient's mother says the boy's condition has worsened over the past 4 days. He has a history of atopic dermatitis. He has lived with his mother at several public shelters since she separated from his physically abusive father 2 months ago. His immunizations are up-to-date. There is cervical lymphadenopathy. Laboratory studies show no abnormalities. A photograph of the rash is shown. Which of the following is the most likely diagnosis?? {'A': 'Bed bug bites', 'B': 'Nonbullous impetigo', 'C': 'Stevens-Johnson syndrome', 'D': 'Eczema herpeticum', 'E': 'Shingles'},
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D: Eczema herpeticum
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Q:A 60-year-old man presents to the emergency department with progressive dyspnea for the last 3 weeks. He complains of shortness of breath while lying flat and reports nighttime awakenings due to shortness of breath for the same duration. The patient has been a smoker for the last 30 years. Past medical history is significant for myocardial infarction 7 months ago. Current medications include metoprolol, aspirin, and rosuvastatin, but the patient is noncompliant with his medications. His temperature is 37.2°C (98.9°F), the blood pressure is 150/115 mm Hg, the pulse is 110/min, and the respiratory rate is 24/min. Oxygen saturation on room air is 88%. Chest auscultation reveals bilateral crackles and an S3 gallop. On physical examination, the cardiac apex is palpated in left 6th intercostal space. Bilateral pitting edema is present, and the patient is in moderate distress. Which of the following is the best next step in the management of the patient?? {'A': 'Intravenous beta blockers', 'B': 'Echocardiography', 'C': 'Cardiac stress testing', 'D': 'Intravenous diuretics', 'E': 'Intravenous inotropes'},
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D: Intravenous diuretics
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Q:A 25-year-old man is brought to the emergency department by police. The patient was found intoxicated at a local bar. The patient is combative and smells of alcohol. The patient has a past medical history of alcoholism, IV drug use, and schizophrenia. His current medications include IM haloperidol and ibuprofen. The patient is currently homeless and has presented to the emergency department similarly multiple times. His temperature is 97.0°F (36.1°C), blood pressure is 130/87 mmHg, pulse is 100/min, respirations are 15/min, and oxygen saturation is 96% on room air. Physical exam is deferred due to patient non-compliance. Laboratory values reveal an acute kidney injury and a normal PT/PTT. The patient is started on IV fluids and ketorolac to control symptoms of a headache. The patient begins to vomit into a basin. The nursing staff calls for help when the patient’s vomit appears grossly bloody. Which of the following best describes the most likely diagnosis?? {'A': 'Dilated submucosal esophageal veins', 'B': 'Gastric mucosal erosion', 'C': 'Mucosal tear at the gastroesophageal junction', 'D': 'Transmural distal esophagus tear', 'E': 'Transmural erosion of the gastric wall'},
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C: Mucosal tear at the gastroesophageal junction
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Q:A 22-year-old man volunteers for a research study on lung function. He has no history of lung disease or allergies and does not smoke. His pulmonary blood flow is measured in the various labeled segments of the lungs while standing. Then the volunteer, still standing, is given very low continuous positive airway pressure and the blood flow measured again. Which of the following sets of findings are most likely to be present in the second measurements relative to the first?? {'A': 'Reduced blood flow in zone 1', 'B': 'Increased blood flow in zone 1', 'C': 'Increased blood flow in zone 2', 'D': 'Reduced blood flow in zone 3', 'E': 'Increased blood flow in zone 3'},
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A: Reduced blood flow in zone 1
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Q:An 8-year-old girl is brought to the pediatrician because she is significantly shorter than her classmates. Her mother notes that she has had thick, oral secretions for the past several months, along with a chronic cough. Her exam is notable for clubbed fingernails. Her pediatrician sends a genetic test for a transmembrane channel mutation, which shows a normal DNA sequence, except for the deletion of three nucleotides that code for a phenylalanine at position 508. What type of mutation has caused her presentation?? {'A': 'Frameshift mutation', 'B': 'In-frame mutation', 'C': 'Nonsense mutation', 'D': 'Triplet expansion', 'E': 'Silent mutation'},
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B: In-frame mutation
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Q:A 4-year-old boy is brought by his parents to his pediatrician’s office. His mother mentions that the child has been producing an increased number of foul stools recently. His mother says that over the past year, he has had 1 or 2 foul-smelling stools per month. Lately, however, the stools are looser, more frequent, and have a distinct odor. Over the past several years, he has been admitted 4 times with episodes of pneumonia. Genetic studies reveal a mutation on a specific chromosome that has led to a 3 base-pair deletion for the amino acid phenylalanine. Which of the following chromosomes is the defective gene responsible for this boy’s clinical condition?? {'A': 'Chromosome 15', 'B': 'Chromosome 4', 'C': 'Chromosome 17', 'D': 'Chromosome 22', 'E': 'Chromosome 7'},
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E: Chromosome 7
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Q:A 37-year-old female presents to the emergency room complaining of headaches and palpitations. She reports that she initially started experiencing these symptoms several months prior but attributed them to stress at work. The symptoms occur episodically. Her family history is notable for medullary thyroid cancer and hyperparathyroidism. Her temperature is 98.6°F (37°C), blood pressure is 165/90 mmHg, pulse is 105/min, and respirations are 18/min. On examination she appears tremulous. Urine metanephrines are elevated. Which of the following is the most appropriate first medication in the management of this patient’s condition?? {'A': 'Phenoxybenzamine', 'B': 'Propranolol', 'C': 'Phentolamine', 'D': 'Tamsulosin', 'E': 'Atenolol'},
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A: Phenoxybenzamine
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Q:A patient is receiving daily administrations of Compound X. Compound X is freely filtered in the glomeruli and undergoes net secretion in the renal tubules. The majority of this tubular secretion occurs in the distal convoluted tubule. Additional information regarding this patient’s renal function and the renal processing of Compound X is included below: Inulin clearance: 120 mL/min Plasma concentration of Inulin: 1 mg/mL PAH clearance: 600 mL/min Plasma concentration of PAH: 0.2 mg/mL Total Tubular Secretion of Compound X: 60 mg/min Net Renal Excretion of Compound X: 300 mg/min Which of the following is the best estimate of the plasma concentration of Compound X in this patient?? {'A': '0.5 mg/mL', 'B': '1 mg/mL', 'C': '2 mg/mL', 'D': '3 mg/mL', 'E': 'There is insufficient information available to estimate the plasma concentration of Compound X'},
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C: 2 mg/mL
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Q:A 22-year-old woman with a history of type I diabetes mellitus presents to the emergency department with nausea, vomiting, and drowsiness for the past day. Her temperature is 98.3°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 120/min, respirations are 27/min, and oxygen saturation is 100% on room air. Physical exam is notable for a confused and lethargic young woman. Initial laboratory values are notable for the findings below. Serum: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 2.9 mEq/L HCO3-: 9 mEq/L BUN: 20 mg/dL Glucose: 599 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L An initial ECG is notable for sinus tachycardia. Which of the following is the best initial step in management for this patient?? {'A': 'Insulin and potassium', 'B': 'Normal saline and insulin', 'C': 'Normal saline and potassium', 'D': 'Normal saline, insulin, and potassium', 'E': 'Normal saline, insulin, potassium, and sodium bicarbonate'},
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C: Normal saline and potassium
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Q:A 57-year-old man comes to the physician for a follow-up visit. Serum studies show: AST 134 U/L ALT 152 U/L Hepatitis B surface antigen Positive A photomicrograph of the microscopic findings of a liver biopsy is shown. These biopsy findings are most characteristic of which of the following types of inflammatory reactions?"? {'A': 'Acute inflammation', 'B': 'Ischemic necrosis', 'C': 'Malignant transformation', 'D': 'Granulomatous inflammation', 'E': 'Chronic inflammation'},
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E: Chronic inflammation
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Q:A 7-day-old male infant presents to the pediatrician for weight loss. There is no history of excessive crying, irritability, lethargy, or feeding difficulty. The parents deny any history of fast breathing, bluish discoloration of lips/nails, fever, vomiting, diarrhea, or seizures. He was born at full term by vaginal delivery without any perinatal complications and his birth weight was 3.6 kg (8 lb). Since birth he has been exclusively breastfed and passes urine six to eight times a day. His physical examination, including vital signs, is completely normal. His weight is 3.3 kg (7.3 lb); length and head circumference are normal for his age and sex. Which of the following is the next best step in the management of the infant?? {'A': 'Reassurance of parents', 'B': 'Emphasize the need to clothe the infant warmly to prevent hypothermia', 'C': 'Evaluation of the mother for malnutrition', 'D': 'Supplementation of breastfeeding with a appropriate infant formula', 'E': 'Admission of the infant in the NICU to treat with empiric intravenous antibiotics'},
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A: Reassurance of parents
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Q:A 16-year-old teenager presents to his pediatrician complaining of burning with urination and purulent urethral discharge. He states that he has had unprotected sex with his girlfriend several times and recently she told him that she has gonorrhea. His blood pressure is 119/78 mm Hg, pulse is 85/min, respiratory rate is 14/min, and temperature is 36.8°C (98.2°F). The urethral meatus appears mildly erythematous, but no pus can be expressed. A testicular examination is normal. An in-office urine test reveals elevated leukocyte esterase levels. An additional swab was taken for further analysis. The patient wants to get treated right away but is afraid because he does not want his parents to know he is sexually active. What is the most appropriate next step for the pediatrician?? {'A': 'Break confidentiality and inform the patient that his parents must consent to this treatment.', 'B': 'Inform the patient that his parents will not be informed, but he cannot receive medical care without their consent.', 'C': 'Maintain confidentiality and treat the patient.', 'D': 'Treat the patient and then break confidentiality and inform the parents of the care he received.', 'E': 'Contact child protective services.'},
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C: Maintain confidentiality and treat the patient.
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Q:A previously healthy 4-year-old boy is brought to the physician by his parents because he has had a fever, diffuse joint pain, and a rash on his abdomen for the past week. Acetaminophen did not improve his symptoms. He emigrated from China with his family 2 years ago. He attends daycare. His immunization records are not available. His temperature is 38.5°C (101.3°F), pulse is 125/min, and blood pressure is 100/60 mm Hg. Examination shows polymorphous truncal rash. The eyes are pink with no exudate. The tongue is shiny and red, and the lips are cracked. The hands and feet are red and swollen. There is right-sided anterior cervical lymphadenopathy. Which of the following is the most appropriate next step in management?? {'A': 'Echocardiography', 'B': 'ANA measurement', 'C': 'Antistreptolysin O titer measurement', 'D': 'Monospot test', 'E': 'HHV-6 immunoglobulin M (IgM) detection'},
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A: Echocardiography
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Q:A 30-year-old woman is brought to the emergency department because of a 30-minute history of palpitations, dizziness, and chest discomfort. She has also not urinated since she woke up. She has a history of fibromyalgia treated with clomipramine. There is no family history of serious illness. She does not smoke or drink alcohol. Her temperature is 37°C (98.6°F), pulse is 120/min, and blood pressure is 90/60 mm Hg. On mental status examination, she is confused. Examination shows dilated pupils and dry skin. The abdomen is distended, there is tenderness to deep palpation of the lower quadrants with no guarding or rebound and dullness on percussion in the suprapubic region. An ECG shows tachycardia and a QRS complex width of 110 ms. Activated carbon is administered. The patient is intubated. Intravenous fluids and oxygenation are begun. Which of the following is the most appropriate pharmacotherapy for this patient?? {'A': 'Glucagon', 'B': 'Naloxone', 'C': 'Cyproheptadine', 'D': 'Sodium bicarbonate', 'E': 'Lorazepam'},
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D: Sodium bicarbonate
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Q:A newborn female is found to have ambiguous genitalia and hypotension. Laboratory workup reveals hyperkalemia, hyperreninemia, and elevated levels of 17-hydroxyprogesterone in the patient's urine. Which of the following enzymes would you expect to be deficient in this patient?? {'A': 'Angiotensin II', 'B': 'DHT', 'C': '17-hydroxylase', 'D': '21-hydroxylase', 'E': '11-hydroxylase'},
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D: 21-hydroxylase
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Answer the following medical question with one of the provided options:
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Q:A 58-year-old woman comes to the physician because of a 3-month history of itching of both legs. She also has swelling and dull pain that are worse at the end of the day and are more severe in her right leg. She has hyperthyroidism, asthma, and type 2 diabetes mellitus. Four years ago, she had basal cell carcinoma of the face that was treated with Mohs surgery. Current medications include methimazole, albuterol, and insulin. She has smoked 3–4 cigarettes a day for the past 29 years. She goes to a local sauna twice a week. Her temperature is 37°C (98.6°F), pulse is 75/min, respirations are 16/min, and blood pressure is 124/76 mm Hg. Physical examination shows fair skin with diffuse freckles. There is 2+ pitting edema of the right leg and 1+ pitting edema of the left leg. There is diffuse reddish-brown discoloration and significant scaling extending from the ankle to the mid-thigh bilaterally. Pedal pulses and sensation are intact bilaterally. Which of the following is the most likely underlying mechanism of this patient's symptoms?? {'A': 'Type IV hypersensitivity reaction', 'B': 'Venous valve incompetence', 'C': 'Malignant proliferation of epidermal keratinocytes', 'D': 'Dermal accumulation of glycosaminoglycans', 'E': 'Breach of skin barrier by dermatophyte'},
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B: Venous valve incompetence
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Answer the following medical question with one of the provided options:
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Q:One hour after undergoing an uncomplicated laparoscopic appendectomy, a 22-year-old man develops agitation and restlessness. He also has tremors, diffuse sweating, headache, and nausea with dry heaves. One liter of lactated ringer's was administered during the surgery and he had a blood loss of approximately 100 mL. His urine output was 100 mL. His pain has been controlled with intravenous morphine. He was admitted to the hospital 3 days ago and has not eaten in 18 hours. He has no history of serious illness. He is a junior in college. His mother has Hashimoto's thyroiditis. He has experimented with intravenous illicit drugs. He drinks 3 beers and 2 glasses of whiskey daily during the week and more on the weekends with his fraternity. He appears anxious. His temperature is 37.4°C (99.3°F), pulse is 120/min, respirations are 19/min, and blood pressure is 142/90 mm Hg. He is alert and fully oriented but keeps asking if his father, who is not present, can leave the room. Mucous membranes are moist and the skin is warm. Cardiac examination shows tachycardia and regular rhythm. The lungs are clear to auscultation. His abdomen has three port sites with clean and dry bandages. His hands tremble when his arms are extended with fingers spread apart. Which of the following is the most appropriate next step in management?? {'A': 'Administer intravenous propranolol', 'B': 'Administer intravenous lorazepam', 'C': 'Administer intravenous naloxone', 'D': 'Adminster intravenous dexamethasone', 'E': 'Administer 5% dextrose in 1/2 normal saline'},
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B: Administer intravenous lorazepam
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Q:A 37-year-old woman comes to the physician because of a 2-week history of palpitations and loose stools. She has had a 2.3-kg (5-lb) weight loss over the past month. She has had no change in appetite. She has no history of serious illness. She works in accounting and has been under more stress than usual lately. She takes no medications. She appears pale. Her temperature is 37.8°C (100.1°F), pulse is 110/min, respirations are 20/min, and blood pressure is 126/78 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender. There is a bilateral hand tremor with outstretched arms and a palpable thyroid nodule in the left lobe. Serum laboratory studies show a thyroid stimulating hormone level of 0.03 μU/mL and a thyroxine level of 28 μg/dL. A radioactive iodine uptake scan shows enhancement in a 3-cm encapsulated nodule in the lower left lobe with decreased uptake in the remaining gland. Which of the following is the most likely diagnosis?? {'A': 'Thyroid storm', 'B': 'Papillary carcinoma', 'C': "Graves' disease", 'D': 'Toxic adenoma', 'E': 'Goiter\n"'},
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D: Toxic adenoma
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Answer the following medical question with one of the provided options:
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Q:A 34-year-old woman, gravida 2, para 0, at 28 weeks' gestation comes to the physician for a prenatal visit. She has not had regular prenatal care. Her most recent ultrasound at 20 weeks of gestation confirmed accurate fetal dates and appropriate fetal development. She takes levothyroxine for hypothyroidism. She used to work as a nurse before she emigrated from Brazil 13 years ago. She lost her immunization records during the move and cannot recall all of her vaccinations. She appears well. Vital signs are within normal limits. Physical examination shows a fundal height of 26 cm and no abnormalities. An ELISA test for HIV is negative. Serology testing for hepatitis B surface antibody and hepatitis C antibody are both positive. Hepatitis B core antibody, hepatitis B surface antigen, and hepatitis A antibody are negative. Polymerase chain reaction of hepatitis C RNA is positive for genotype 1. Which of the following is the most appropriate recommendation at this time?? {'A': 'Start combination therapy with interferon α and ribavirin', 'B': 'Undergo liver biopsy', 'C': 'Hepatitis A vaccination', 'D': 'Schedule a cesarean delivery', 'E': 'Plan to give hepatitis B vaccine and hepatitis B Ig to the newborn'},
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C: Hepatitis A vaccination
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Answer the following medical question with one of the provided options:
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Q:A 47-year-old woman comes to the physician because of involuntary leakage of urine for the past 4 months, which she has experienced when bicycling to work and when laughing. She has not had any dysuria or urinary urgency. She has 4 children that were all delivered vaginally. She is otherwise healthy and takes no medications. The muscles most likely affected by this patient's condition receive efferent innervation from which of the following structures?? {'A': 'S1-S2 nerve roots', 'B': 'Superior gluteal nerve', 'C': 'Superior hypogastric plexus', 'D': 'Obturator nerve', 'E': 'S3–S4 nerve roots'},
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E: S3–S4 nerve roots
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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 the urgent care center with a blood pressure of 201/111 mm Hg. He is complaining of a severe headache and chest pain. Physical examination reveals regular heart sounds and clear bilateral lung sounds. Ischemic changes are noted on his electrocardiogram (ECG). What is the most appropriate treatment for this patient’s high blood pressure?? {'A': 'Oral clonidine - gradually lower blood pressure over 24–48 hours', 'B': 'Oral beta-blocker - lower mean arterial pressure no more than 25% over the 1st hour', 'C': 'IV labetalol - redose until blood pressure within normal limits', 'D': 'IV labetalol - lower mean arterial pressure no more than 50% over the 1st hour', 'E': 'IV labetalol - lower mean arterial pressure no more than 25% over the 1st hour'},
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E: IV labetalol - lower mean arterial pressure no more than 25% over the 1st hour
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Answer the following medical question with one of the provided options:
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Q:A large pharmaceutical company is seeking healthy volunteers to participate in a drug trial. The drug is excreted in the urine, and the volunteers must agree to laboratory testing before enrolling in the trial. The laboratory results of one volunteer are shown below: Serum glucose (random) 148 mg/dL Sodium 140 mEq/L Potassium 4 mEq/L Chloride 100 mEq/L Serum creatinine 1 mg/dL Urinalysis test results: Glucose absent Sodium 35 mEq/L Potassium 10 mEq/L Chloride 45 mEq/L Creatinine 100 mg/dL Assuming a urine flow rate of 1 mL/min, which set of values below is the clearance of glucose, sodium, and creatinine in this patient?? {'A': 'Glucose: 0 mg/dL, Sodium: 45 mL/min, Creatinine: 100 mg/dL', 'B': 'Glucose: 0 mg/dL, Sodium: 0.25 mL/min, Creatinine: 100 mg/dL', 'C': 'Glucose: 0 mg/dL, Sodium: 48 mL/min, Creatinine: 100 mg/dL', 'D': 'Glucose: 148 mg/dL, Sodium: 105 mL/min, Creatinine: 99 mg/dL', 'E': 'Glucose: 0 mg/dL, Sodium: 4 mL/min, Creatinine: 0.01 mg/dL'},
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B: Glucose: 0 mg/dL, Sodium: 0.25 mL/min, Creatinine: 100 mg/dL
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Answer the following medical question with one of the provided options:
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Q:A 52-year-old woman complains of intermittent diffuse abdominal pain that becomes worse after eating meals and several episodes of diarrhea, the last of which was bloody. These symptoms have been present for the previous 6 months but have worsened recently. She has had significant weight loss since the onset of symptoms. Her past medical history includes systemic lupus erythematosus (SLE), which has been difficult to manage medically. Vital signs include a blood pressure of 100/70 mm Hg, temperature of 37.1°C (98.8 °F), and pulse of 95/min. On physical examination, the patient appears to be in severe pain, and there is mild diffuse abdominal tenderness. Which of the following is the most likely diagnosis?? {'A': 'Gastroenteritis', 'B': 'Ischemic bowel disease', 'C': 'Ulcerative colitis', 'D': 'Small bowel obstruction', 'E': 'Acute pancreatitis'},
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B: Ischemic bowel disease
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Answer the following medical question with one of the provided options:
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Q:A healthy 29-year-old woman comes to the doctor because of recurrent episodes of bleeding from the nose and gums during the past week. These episodes occur spontaneously and resolve with compression. She also had 1 episode of blood in the urine 2 days ago. Examination shows punctate, nonblanching, reddish macules over the neck, chest, and lower extremities. Her leukocyte count is 8,600/mm3, hemoglobin concentration is 12.9 g/dL, and platelet count is 26,500/mm3. A peripheral blood smear shows a reduced number of platelets with normal morphology. Evaluation of a bone marrow biopsy in this patient is most likely to show which of the following findings?? {'A': 'Erythroid hyperplasia', 'B': 'Ringed sideroblasts', 'C': 'Absence of hematopoietic cells', 'D': 'Megakaryocyte hyperplasia', 'E': 'Plasma cell hyperplasia'},
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D: Megakaryocyte hyperplasia
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Answer the following medical question with one of the provided options:
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Q:A 26-year-old man comes to the emergency department because of a 1-week history of worsening fatigue, nausea, and vomiting. Six weeks ago, he was diagnosed with latent tuberculosis and appropriate low-dose pharmacotherapy was initiated. Physical examination shows right upper quadrant tenderness and scleral icterus. Laboratory studies show elevated aminotransferases. Impaired function of which of the following pharmacokinetic processes is the most likely explanation for this patient's symptoms?? {'A': 'Sulfation', 'B': 'Hydrolysis', 'C': 'Glucuronidation', 'D': 'Reduction', 'E': 'Acetylation'},
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E: Acetylation
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