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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 42-year-old woman comes to the physician for a routine health maintenance examination. She has generalized fatigue and has had difficulties doing her household duties for the past 3 months. She has eczema and gastroesophageal reflux disease. She has a history of using intravenous methamphetamine in her youth but has not used illicit drugs in 23 years. Her medications include topical clobetasol and pantoprazole. She is 160 cm (5 ft 3 in) tall and weighs 105 kg (231 lb); BMI is 42 kg/m2. Her temperature is 37°C (98.6°F), pulse is 95/min, and blood pressure is 145/90 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Pelvic examination shows a normal vagina and cervix. Laboratory studies show: Hemoglobin 13.1 g/dL Leukocyte count 7,800/mm3 Platelet count 312,000/mm3 Serum Na+ 141 mEq/L K+ 4.6 mEq/L Cl- 98 mEq/L Urea nitrogen 12 mg/dL Fasting glucose 110 mg/dL Creatinine 0.8 mg/dL Total cholesterol 269 mg/dL HDL-cholesterol 55 mg/dL LDL-cholesterol 160 mg/dL Triglycerides 320 mg/dL Urinalysis is within normal limits. An x-ray of the chest shows no abnormalities. She has not lost any weight over the past year despite following supervised weight loss programs, including various diets and exercise regimens. Which of the following is the most appropriate next step in management of this patient?" (A) Liposuction (B) Bariatric surgery (C) Behavioral therapy (D) Phentermine and topiramate therapy and follow-up in 3 months
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['(B) Bariatric surgery <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 70 year-old man comes to the physician for difficulty swallowing for 6 months. During this time, he has occasionally coughed up undigested food. He did not have weight loss or fever. Four weeks ago, he had an episode of sore throat, that resolved spontaneously. He has smoked one pack of cigarettes daily for 5 years. He has gastroesophageal reflux disease and osteoporosis. Current medications include alendronate and omeprazole. His temperature is 37.0°C (98.6°F), pulse is 84/min, and blood pressure is 130/90 mmHg. On examination, he has foul-smelling breath and a fluctuant mass on the right neck. Which of the following is most likely involved in the pathogenesis of this patient's symptoms? (A) Deep neck space infection (B) Degeneration of neurons in the esophageal wall (C) Cellular dysplasia (D) Abnormal esophageal motor function
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['(D) Abnormal esophageal motor function <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A graduate student in public health is conducting a study on population health and is comparing different demographic models. He is particularly interested in investigating health care interventions in societies with the demographic distribution shown. Which of the following measures is most likely to ensure a healthy demographic transition in this population? (A) Invest in workplace health and safety measures (B) Invest in childhood immunization programs (C) Invest in prostate cancer screening programs (D) Invest in long-term care facilities
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['(B) Invest in childhood immunization programs <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 60-year-old man is brought to the emergency department because of a 30-minute history of dizziness and shortness of breath. After establishing the diagnosis, treatment with a drug is administered. Shortly after administration, the patient develops severe left eye pain and decreased vision of the left eye, along with nausea and vomiting. Ophthalmologic examination shows a fixed, mid-dilated pupil and a narrowed anterior chamber of the left eye. The patient was most likely treated for which of the following conditions? (A) Atrioventricular block (B) Hypertensive crisis (C) Mitral regurgitation (D) Viral pleuritis
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['(A) Atrioventricular block <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 19-year-old nulligravid woman comes to the physician because of irregular heavy menstrual bleeding since menarche at age 16 years. Menses occur at irregular 15- to 45-day intervals and last 7 to 10 days. She has also noted increased hair growth on her face. She has not been sexually active since she started taking isotretinoin for acne vulgaris 4 months ago. Her 70-year-old grandmother has breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 74 kg (163 lb); BMI is 28 kg/m2. Pelvic examination shows copious cervical mucus and slightly enlarged irregular ovaries. If left untreated, this patient is at an increased risk for which of the following complications? (A) Endometrial cancer (B) Osteoporosis (C) Proximal myopathy (D) Breast cancer
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['(A) Endometrial cancer <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 32-year-old man comes to the office for a routine health maintenance examination. He admits to recently having an affair several months ago and requests STD testing. One week later, the results of a fourth-generation HIV antibody and antigen test return positive. The patient is counseled on the test result. The patient requests that his diagnosis not be disclosed to anyone, including his wife. The man's wife is also the physician's patient. Which of the following is the most appropriate next step by the physician? (A) Report the infection to the national health authorities (B) Inform the wife immediately of the positive result (C) Offer the patient repeat antibody testing to confirm results (D) Wait for one week before you disclose the results to his wife
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['(A) Report the infection to the national health authorities <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 4-day-old boy is monitored in the well baby nursery. He was born to a G1P1 mother at 36 weeks gestation. The child is doing well, and the mother is recovering from vaginal delivery. On physical exam, there is an arousable infant who is crying vigorously and is mildly cyanotic. A red reflex is noted bilaterally on ophthalmologic exam. The infant's fontanelle is soft, and his sucking reflex is present. A positive Babinski sign is noted on physical exam bilaterally. A continuous murmur is auscultated on cardiac exam. Which of the following would most likely have prevented the abnormal finding in this infant? (A) Betamethasone (B) Folic acid (C) Indomethacin (D) Prostaglandins
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['(C) Indomethacin <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 4-month-old boy is brought to the physician because of a seizure. He was delivered at term after an uncomplicated pregnancy. He is currently at the 10th percentile for height, 5th percentile for weight, and 15th percentile for head circumference. Examination shows muscle hypotonia. His serum lactic acid and alanine are elevated. A functional assay of pyruvate dehydrogenase complex in serum leukocytes shows decreased enzyme activity. Supplementation with which of the following substances should be avoided in this patient? (A) Arachidonic acid (B) Valine (C) Lysine (D) Thiamine
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['(B) Valine <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 7-year-old boy with a history of cystic fibrosis is brought to the physician for evaluation of recurrent episodes of productive cough, wheezing, and shortness of breath over the past month. Physical examination shows coarse crackles and expiratory wheezing over both lung fields. Serum studies show elevated levels of IgE and eosinophilia. A CT scan of the lungs shows centrally dilated bronchi with thickened walls and peripheral airspace consolidation. Antibiotic therapy is initiated. One week later, the patient continues to show deterioration in lung function. A sputum culture is most likely to grow which of the following? (A) Monomorphic, septate hyphae that branch at acute angles (B) Dimorphic, cigar-shaped budding yeast (C) Monomorphic, narrow budding encapsulated yeast (D) Monomorphic, broad, nonseptate hyphae that branch at wide angles
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['(A) Monomorphic, septate hyphae that branch at acute angles <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An investigator for a nationally representative health survey is evaluating the heights and weights of men and women aged 18–74 years in the United States. The investigator finds that for each sex, the distribution of heights is well-fitted by a normal distribution. The distribution of weight is not normally distributed. Results are shown: Mean Standard deviation Height (inches), men 69 0.1 Height (inches), women 64 0.1 Weight (pounds), men 182 1.0 Weight (pounds), women 154 1.0 Based on these results, which of the following statements is most likely to be correct?" (A) 68% of weights in women are likely to fall between 153 and 155 pounds. (B) 99.7% of heights in women are likely to fall between 63.7 and 64.3 inches. (C) 99.7% of heights in men are likely to fall between 68.8 and 69.2 inches. (D) 95% of heights in men are likely to fall between 68.85 and 69.15 inches.
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['(B) 99.7% of heights in women are likely to fall between 63.7 and 64.3 inches. <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 48-year-old man presents to the emergency department with shortness of breath. He reports that 6 months ago he was able to walk several miles without stopping. Yesterday, he became short of breath walking from his bed to the bathroom. He also endorses worsening abdominal distension and leg swelling, which he reports is new from several months ago. The patient has a past medical history of hypertension and hyperlipidemia. On physical exam, the patient has moderate abdominal distension and pitting edema to the knee. Crackles are present at the bilateral bases. Laboratory testing reveals the following: Hemoglobin: 13.4 g/dL Mean corpuscular volume (MCV): 102 um^3 Leukocyte count: 11,200 /mm^3 with normal differential Platelet count: 256,000/mm^3 Serum: Na+: 137 mEq/L Cl-: 100 mEq/L K+: 4.2 mEq/L HCO3-: 25 mEq/L BUN: 18 mg/dL Glucose: 126 mg/dL Creatinine: 0.9 mg/dL Alkaline phosphatase: 88 U/L Aspartate aminotransferase (AST): 212 U/L Alanine aminotransferase (ALT): 104 U/L Which of the following is the best next step in management? (A) Alcohol cessation (B) Antiviral therapy (C) Hormone replacement (D) Vitamin repletion
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['(A) Alcohol cessation <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 24-year-old woman presents to the emergency department for chest pain and shortness of breath. She was at home making breakfast when her symptoms began. She describes the pain as sharp and located in her chest. She thought she was having a heart attack and began to feel short of breath shortly after. The patient is a college student and recently joined the soccer team. She has no significant past medical history except for a progesterone intrauterine device which she uses for contraception, and a cyst in her breast detected on ultrasound. Last week she returned on a trans-Atlantic flight from Russia. Her temperature is 98.4°F (36.9°C), blood pressure is 137/69 mmHg, pulse is 98/min, respirations are 18/min, and oxygen saturation is 99% on room air. Physical exam reveals an anxious young woman. Cardiac and pulmonary exam are within normal limits. Deep inspiration and palpation of the chest wall elicits pain. Neurologic exam reveals a stable gait and cranial nerves II-XII are grossly intact. Which of the following best describes the most likely underlying etiology? (A) Clot in the pulmonary arteries (B) Ischemia of the myocardium (C) Musculoskeletal inflammation (D) Psychogenic etiology
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['(C) Musculoskeletal inflammation <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 48-year-old man comes to the emergency room for a persistent painful erection for the last 4 hours. Three weeks ago, he had a deep vein thrombosis following a 13-hour flight. He also has a history of sickle cell trait, gastroesophageal reflux disease, major depressive disorder, and hypertension. He has smoked 1 pack of cigarette daily for the past 9 years. He takes warfarin, propranolol, citalopram, trazodone, lisinopril, and omeprazole. He is alert and oriented but in acute distress. His temperature is 37°C(98.6°F), pulse is 109/min, and blood pressure is 139/88 mm Hg. Examination shows a rigid erection with no evidence of trauma, penile discharge, injection, or prosthesis. Which of the following is the most likely cause of his condition? (A) Cigarette smoking (B) Trazodone (C) Sickle cell trait (D) Citalopram
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['(B) Trazodone <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A patient is in the ICU for diabetic ketoacidosis and is currently on an insulin drip. His electrolytes are being checked every hour and his potassium is notable for the following measures: 1. 5.1 mEq/L 2. 5.8 mEq/L 3. 6.1 mEq/L 4. 6.2 mEq/L 5. 5.9 mEq/L 6. 5.1 mEq/L 7. 4.0 mEq/L 8. 3.1 mEq/L Which of the following is the median potassium value of this data set? (A) 3.10 (B) 5.10 (C) 5.16 (D) 5.45
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['(D) 5.45 <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 27-year-old woman, gravida 2, para 1, at 36 weeks' gestation comes to the physician for a prenatal visit. She feels well. Fetal movements are adequate. This is her 7th prenatal visit. She had an ultrasound scan performed 1 month ago that showed a live intrauterine pregnancy consistent with a 32-week gestation with no anomalies. She had a Pap smear performed 1 year ago, which was normal. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Her blood group and type is A negative. Which of the following is the most appropriate next step in management? (A) Complete blood count (B) Transabdominal doppler ultrasonography (C) Serum PAPP-A and HCG levels (D) Swab for GBS culture
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['(D) Swab for GBS culture <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 73-year-old woman comes to the physician because of recurrent episodes of losing consciousness for several seconds upon standing. She has a history of hypertension, which has been treated with hydrochlorothiazide. Her blood pressure is 130/87 mm Hg in the supine position and 100/76 mm Hg 30 seconds after standing up. Cardiac examination shows no abnormalities. Which of the following sets of changes is most likely to occur when the patient stands up? $$$ Venous return %%% Carotid sinus baroreceptor activity %%% Cerebral blood flow $$$ (A) ↓ ↓ ↓ (B) ↑ ↑ ↑ (C) No change ↓ ↓ (D) ↓ ↑ ↓
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['(A) ↓ ↓ ↓ <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 3-year-old girl is brought to the emergency department by her parents with sudden onset shortness of breath. They tell the emergency physician that their daughter was lying on the bed watching television when she suddenly began gasping for air. They observed a bowl of peanuts lying next to her when they grabbed her up and brought her to the emergency department. Her respirations are 25/min, the pulse is 100/min and the blood pressure is 90/65 mm Hg. The physical findings as of now are apparently normal. She is started on oxygen and is sent in for a chest X-ray. Based on her history and physical exam findings, the cause of her current symptoms would be seen on the X-ray at which of the following sites? (A) The apical segment of the right upper lobe (B) The apical segment of the left upper lobe (C) The superior segment of the right lower lobe (D) The posterior segment of the right lower lobe
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['(C) The superior segment of the right lower lobe <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 19-year-old woman presents with an irregular menstrual cycle. She says that her menstrual cycles have been light with irregular breakthrough bleeding for the past three months. She also complains of hair loss and increased the growth of facial and body hair. She had menarche at 11. Vital signs are within normal limits. Her weight is 97.0 kg (213.8 lb) and height is 157 cm (5 ft 2 in). Physical examination shows excessive hair growth on the patient’s face, back, linea alba region, and on the hips. There is also a gray-brown skin discoloration on the posterior neck. An abdominal ultrasound shows multiple peripheral cysts in both ovaries. Which of the following cells played a direct role in the development of this patient’s excessive hair growth? (A) Ovarian follicular cells (B) Pituitary gonadotropic cells (C) Ovarian theca cells (D) Pituitary lactotrophs
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['(C) Ovarian theca cells <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 42-year-old homeless male presents with fever and cough. He was found unconscious on the side of the road and was brought to the emergency room. He is noticeably drunk and is unable to answer any questions. On physical exam his temperature is 103°F (40°C), blood pressure is 130/85 mmHg, pulse is 110/min, respirations are 23/min, and pulse oximetry is 96% on room air. You note decreased breath sounds in the right lower lobe. The pathogen most likely responsible for this patient's symptoms has which of the following features? (A) Organism that forms black colonies on cysteine-tellurite agar (B) Disc-shaped yeast seen on methenamine silver stain (C) Negative-sense, single-stranded RNA virus (D) Gram-negative organism that produces mucoid colonies on MacConkey agar
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['(D) Gram-negative organism that produces mucoid colonies on MacConkey agar <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An investigator is studying genetic mutations of coagulation factors from patient samples. Genetic sequencing of one patient's coagulation factors shows a DNA point mutation that substitutes guanine for adenine. The corresponding mRNA codon forms a glutamine in place of arginine on position 506 at the polypeptide cleavage site. This patient's disorder is most likely to cause which of the following? (A) Petechiae (B) Cerebral vein thrombosis (C) Hemarthrosis (D) Ischemic stroke
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['(B) Cerebral vein thrombosis <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 55-year-old man comes to the physician because of progressive daytime sleepiness and exertional dyspnea for the past 6 months. Physical examination shows conjunctival pallor and several subcutaneous purple spots on his legs. His hemoglobin concentration is 8.5 g/dL, leukocyte count is 3,000/mm3, and platelet count is 16,000/mm3. Which of the following laboratory values is most likely to be increased in this patient? (A) Haptoglobin concentration (B) Transferrin concentration (C) Reticulocyte count (D) Erythropoietin concentration
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['(D) Erythropoietin concentration <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 66-year-old man comes to the physician because of difficulty walking for the past year. He reports that his gait has become slower and that initiating steps has become more challenging. During the past 6 months, his family has noticed that he is starting to forget important family meetings and holidays. On a number of occasions, he has not been able to get to the bathroom in time in order to urinate. He has hypertension treated with hydrochlorothiazide. His father died of Parkinson's disease at the age of 63 years. The patient had smoked one pack of cigarettes daily for 40 years, but quit 10 years ago. His vital signs are within normal limits. On mental status examination, he is confused and has short-term memory deficits. He has a wide-based, shuffling gait. Muscle strength is normal. Deep tendon reflexes are 2+ bilaterally. An MRI of the head is shown. Which of the following is the most likely underlying cause of this patient's symptoms? (A) Normal changes associated with aging (B) Decreased cerebrospinal fluid absorption (C) Obstructed passage of cerebrospinal fluid (D) Degeneration of cholinergic neurons in the temporal lobe
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['(B) Decreased cerebrospinal fluid absorption <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An 82-year-old man with alcohol use disorder is brought to the emergency department from his assisted living facility because of fever and cough for 1 week. The cough is productive of thick, mucoid, blood-tinged sputum. His temperature is 38.5°C (101.3°F) and respirations are 20/min. Physical examination shows coarse inspiratory crackles over the right lung field. Sputum cultures grow gram-negative, encapsulated bacilli that are resistant to amoxicillin, ceftriaxone, and aztreonam. Which of the following infection control measures is most appropriate for preventing transmission of this organism to other patients in the hospital? (A) Require all staff and visitors to wear droplet masks (B) Require autoclave sterilization of all medical instruments (C) Isolate patient to a single-occupancy room (D) Transfer patient to a negative pressure room
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['(C) Isolate patient to a single-occupancy room <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 46-year-old man presents to his primary care provider for an ulcerating skin lesion on his leg for the past week. He says that the week prior he slipped while hiking and scraped his left leg. Over the course of the next week, he noticed redness and swelling of the scraped area and the development of a nodule that eventually ulcerated. On exam, his temperature is 99.5°F (37.5°C), blood pressure is 136/92 mmHg, pulse is 88/min, and respirations are 12/min. Over his left lateral leg is an erythematous patch with a 2-cm nodule with central ulceration. Staining of a sample from the nodule demonstrates gram-positive organisms that are also weakly acid-fast. Morphologically, the organism appears as branching filaments. Which of the following should be used to treat this infection? (A) Doxycycline (B) Penicillin (C) Streptomycin (D) Trimethoprim-sulfamethoxazole
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['(D) Trimethoprim-sulfamethoxazole <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 68-year-old man is admitted to the emergency department after 2 days of difficulty breathing and fever. His past medical history is significant for hypertension and benign prostate hypertrophy. He takes hydrochlorothiazide and tamsulosin. He also admits to drinking alcohol on the weekends and a half pack a day smoking habit. Upon admission, he is found to have blood pressure of 125/83 mm Hg, pulse of 88/min, a respiratory rate of 28/min, and a temperature of 38.9°C (102°F). On physical exam breath sounds are decreased at the left pulmonary base. A chest x-ray reveals consolidation in the left lower lobe. Additional laboratory tests demonstrate leukocytosis, elevated C-reactive protein, a serum creatinine (Cr) of 8.0 mg/dL, and a blood urea nitrogen (BUN) of 32 mg/dL. The patient is admitted to the hospital and started on cefepime and clarithromycin. His dyspnea slowly improves after 48 hours, however, his body temperature remains at 39°C (102.2°F). Recent laboratory tests show reduced C-reactive protein levels, a Cr of 1.8 mg/dL and a BUN of 35 mg/dL. A urinalysis is ordered. Which of the following would you expect to find in this patient’s urine? (A) White blood cell casts (B) Urate crystals (C) Hyaline casts (D) Calcium oxalate crystals
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['(A) White blood cell casts <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An investigator is developing a drug for muscle spasms. The drug inactivates muscular contraction by blocking the site where calcium ions bind to the myocyte actin filament. Which of the following is the most likely site of action of this drug? (A) Myosin-binding site (B) Myosin head (C) Acetylcholine receptor (D) Troponin C
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['(D) Troponin C <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 34-year-old woman presents with acute onset loss of vision and visual disturbances. She says that, several hours ago, her vision began to get dim, and she sees halos around light sources. This was immediately followed by a severe frontal headache. Past medical history is significant for epilepsy. The patient says her anticonvulsant medication was changed recently but she doesn’t remember the name. Slit-lamp examination reveals mild chemosis, injection, and ciliary flush with diffuse stromal haze, along with very shallow peripheral anterior chambers with areas of iridocorneal touch in both eyes. Gonioscopy showed closed angles bilaterally. Which of the following antiepileptic drugs is most likely responsible for this patient’s condition? (A) Lamotrigine (B) Topiramate (C) Gabapentin (D) Tiagabine
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['(B) Topiramate <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 7-year-old boy is brought to the pediatrician by his parents due to pubic hair growth and changes in his voice. He has been developing in the 98th percentile for his age. His vaccination is up-to-date. The patient’s blood pressure is within the 60th percentile for his age. Physical examination reveals pubic and armpit hair, and Tanner stage 2 characterized by enlarged scrotum and testes. Laboratory findings are significant for the following: Hemoglobin 13.1 g/dL Hematocrit 39.7% Leukocyte count 8,500/mm3 Neutrophils 65% Lymphocytes 30% Monocytes 5% Mean corpuscular volume 82.2 μm3 Platelet count 20,000/mm3 Urine creatinine clearance 98 mL/min Serum 17-hydroxyprogesterone 313 ng/dL (normal <110 ng/dL) Which of the following enzymes is most likely to be defective in this patient? (A) 17-α-hydroxylase (B) 5-α-reductase (C) 21-hydroxylase (D) Aromatase
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['(C) 21-hydroxylase <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 42-year-old woman presents to the emergency department in active labor. She has had no prenatal care and is unsure of the gestational age. Labor progresses rapidly and spontaneous vaginal delivery of a baby boy occurs 3 hours after presentation. On initial exam, the child is 1.9 kg (4.2 lb) with a small head and jaw. A sac-like structure containing intestine, as can be seen in the picture, protrudes from the abdominal wall. What complication is closely associated with this presentation? (A) Duodenal atresia (B) Dehydration and necrosis of bowel (C) Cardiac defect (D) Twisting of the bowel around itself
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['(C) Cardiac defect <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 21-year-old woman comes to the physician because of a 4-month history of fatigue. She admits to binge eating several times per month, after which she usually induces vomiting for compensation. She exercises daily in an effort to lose weight. She is 168 cm (5 ft 6 in) tall and weighs 60 kg (132 lb); BMI is 21.3 kg/m2. Physical examination shows calluses on the knuckles and bilateral parotid gland enlargement. Oropharyngeal examination shows eroded dental enamel and decalcified teeth. Which of the following is the most appropriate pharmacotherapy for this patient's condition? (A) Orlistat (B) Mirtazapine (C) Venlafaxine (D) Fluoxetine
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['(D) Fluoxetine <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 61-year-old female with a history of breast cancer currently on chemotherapy is brought by her husband to her oncologist for evaluation of a tremor. She reports that she developed a hand tremor approximately six months ago, prior to the start of her chemotherapy. The tremor is worse at rest and decreases with purposeful movement. She has experienced significant nausea and diarrhea since the start of her chemotherapy. Her past medical history is also notable for diabetes and hypertension treated with metformin and lisinopril, respectively. She takes no other medications. On examination, there is a tremor in the patient’s left hand. Muscle tone is increased in the upper extremities. Gait examination reveals difficulty initiating gait and shortened steps. Which of the following medications is contraindicated in the management of this patient’s nausea and diarrhea? (A) Ondansetron (B) Diphenhydramine (C) Loperamide (D) Metoclopramide
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['(D) Metoclopramide <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 24-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was a restrained driver. On arrival, he is alert and oriented. His pulse is 112/min, respirations are 29/min, and blood pressure is 100/60 mm Hg. The pupils are equal and reactive to light. There is a 3-cm laceration over the forehead and multiple bruises over the trunk. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. The abdomen is soft and nontender. The right knee is swollen and tender; range of motion is limited by pain. Infusion of 0.9% saline is begun and intravenous acetaminophen is administered. Two hours later, blood-tinged fluid spontaneously drains from both nostrils, and is made worse by leaning forward. On a piece of gauze, it shows up as a rapidly-expanding clear ring of fluid surrounding blood. Further evaluation of this patient is most likely to show which of the following? (A) Cranial nerve XII palsy (B) Bilateral periorbital ecchymosis (C) Numbness of upper cheek area (D) Retroauricular ecchymosis "
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['(B) Bilateral periorbital ecchymosis <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** The patient declines the use of oxytocin or any other further testing and decides to await a spontaneous delivery. Five weeks later, she comes to the emergency department complaining of vaginal bleeding for 1 hour. Her pulse is 110/min, respirations are 18/min, and blood pressure is 112/76 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Pelvic examination shows active vaginal bleeding. Laboratory studies show: Hemoglobin 12.8 g/dL Leukocyte count 10,300/mm3 Platelet count 105,000/mm3 Prothrombin time 26 seconds (INR=1.8) Serum Na+ 139 mEq/L K+ 4.1 mEq/L Cl- 101 mEq/L Urea nitrogen 42 mg/dL Creatinine 2.8 mg/dL Which of the following is the most likely underlying mechanism of this patient's symptoms?" (A) Decreased synthesis of coagulation factors (B) Separation of the placenta from the uterus (C) Thromboplastin in maternal circulation (D) Amniotic fluid in maternal circulation
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['(C) Thromboplastin in maternal circulation <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A pulmonary autopsy specimen from a 58-year-old woman who died of acute hypoxic respiratory failure was examined. She had recently undergone surgery for a fractured femur 3 months ago. Initial hospital course was uncomplicated, and she was discharged to a rehab facility in good health. Shortly after discharge home from rehab, she developed sudden shortness of breath and had cardiac arrest. Resuscitation was unsuccessful. On histological examination of lung tissue, fibrous connective tissue around the lumen of the pulmonary artery is observed. Which of the following is the most likely pathogenesis for the present findings? (A) Thromboembolism (B) Pulmonary ischemia (C) Pulmonary hypertension (D) Pulmonary passive congestion
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['(A) Thromboembolism <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** Urinalysis shows: Protein 1+ Leukocyte esterase positive Nitrite positive RBC 2/hpf WBC 90/hpf WBC casts numerous Which of the following is the most appropriate next step in management?" (A) Treat on an outpatient basis with nitrofurantoin (B) Admit the patient and perform an CT scan of the abdomen (C) Treat on an outpatient basis with ciprofloxacin (D) Admit the patient and treat with intravenous levofloxacin
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['(C) Treat on an outpatient basis with ciprofloxacin <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An investigator studying mechanisms of acquired antibiotic resistance in bacteria conducts a study using isolated strains of Escherichia coli and Staphylococcus aureus. The E. coli strain harbors plasmid pRK212.1, which conveys resistance to kanamycin. The S. aureus strain is susceptible to kanamycin. Both bacterial strains are mixed in a liquid growth medium containing deoxyribonuclease. After incubation for 2 days and subsequent transfer to a solid medium, the S. aureus colonies show no lysis in response to the application of kanamycin. Analysis of chromosomal DNA from the kanamycin-resistant S. aureus strain does not reveal the kanamycin-resistance gene. Which of the following mechanisms is most likely responsible for this finding? (A) Transformation (B) Conjugation (C) Transposition (D) Transduction
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['(B) Conjugation <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 30-year-old man is brought to the emergency department with complaints of fevers to 39.0℃ (102.2℉) and diarrhea for the past 12 hours. There is no history of headaches, vomiting, or loss of consciousness. The past medical history is unobtainable because the patient recently immigrated from abroad and has a language barrier, but his wife says that her husband had a motor vehicle accident when he was a teenager that required emergent surgery. He is transferred to the ICU after a few hours in the ED due to dyspnea, cyanosis, and hemodynamic collapse. There are no signs of a meningeal infection. The blood pressure is 70/30 mm Hg at the time of transfer. A chest X-ray at the time of admission shows interstitial infiltrates without homogeneous opacities. The initial laboratory results reveal metabolic acidosis, leukopenia with a count of 2000/mm3, thrombocytopenia (15,000/mm3), and a coagulation profile suggesting disseminated intravascular coagulation. A peripheral smear is performed as shown in the accompanying image. Despite ventilatory support, administration of intravenous fluids, antibiotics, and vasopressor agents, the patient dies the next day. The gram stain from the autopsy specimen of his lungs reveals gram-positive, lancet-shaped diplococci occurring singly and in chains. Which of the following organisms is the most likely cause for the patient’s condition? (A) Staphylococcus aureus (B) Streptococcus pneumoniae (C) Neisseria meningitidis (D) Non-typeable H. influenzae
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['(B) Streptococcus pneumoniae <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 26-year-old woman is brought to the emergency department after a motor vehicle accident. She was driving on the highway when she was struck by a van. At the hospital she was conscious but was bleeding heavily from an open wound in her left leg. Pulse is 120/min and blood pressure is 96/68 mm Hg. She receives 3 L of intravenous saline and her pulse slowed to 80/min and blood pressure elevated to 116/70 mm Hg. The next morning she is found to have a hemoglobin of 6.2 g/dL. Her team decides to transfuse 1 unit of packed RBCs. Twenty minutes into the transfusion she develops a diffuse urticarial rash, wheezing, fever, and hypotension. The transfusion is immediately stopped and intramuscular epinephrine is administered. Which of the following scenarios is most consistent with this patient's reaction to the blood transfusion? (A) A patient history of cardiovascular disease (B) Facial twitching when the patient's cheek is tapped (C) A patient history of frequent sinopulmonary infections (D) Unsanitary blood product storage practices in the hospital
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['(C) A patient history of frequent sinopulmonary infections <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 50-year-old man presents to the emergency department with a severe headache. The patient reports that it started approx. 2 hours ago and has steadily worsened. He describes it as a stabbing pain localized behind his left eye. The patient reports that he has been having similar headaches several times a day for the past week, most often at night. He denies any nausea, vomiting, and visual or auditory disturbances. He has no significant past medical history. Current medications are a multivitamin and caffeine pills. The patient reports regular daily alcohol use but does not smoke. His temperature is 37.0°C (98.6°F), the blood pressure is 120/70 mm Hg, the pulse is 85/min, the respiratory rate is 18/min, and the oxygen saturation is 99% on room air. The patient is in moderate distress from the pain. The physical exam is significant for unilateral diaphoresis on the left forehead, left-sided rhinorrhea, and pronounced lacrimation of the left eye. The remainder of the physical exam is normal. Laboratory tests are normal. Non-contrast CT of the head shows no evidence of intracranial masses or hemorrhage. High flow oxygen and fluid resuscitation are initiated. Ibuprofen 200 mg orally is administered. Despite these interventions, the patient continues to be in significant pain. What is the next best step in management? (A) Verapamil (B) CT angiography (C) Administer subcutaneous sumatriptan (D) Deep brain stimulation of the posterior inferior hypothalamus
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['(C) Administer subcutaneous sumatriptan <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 24-year-old woman of Ashkenazi Jewish descent presents with recurrent bloody diarrhea and abdominal pain. She says she feels well otherwise. Review of systems is significant for a 4 kg weight loss over the past month. Physical examination is significant for multiple aphthous oral ulcers. Colonoscopy reveals a cobblestone pattern of lesions of the mucosa of the intestinal wall involving the sigmoid colon. The patient is informed of the diagnosis and medication to treat her condition is prescribed. On a follow-up visit 6 weeks later, the patient presents with non-productive cough, chest pain, dyspnea on exertion, and worsening oral lesions. A chest radiograph reveals a diffuse interstitial pattern. Which of the following enzymes is inhibited by the medication most likely prescribed for her initial diagnosis? (A) Thymidylate synthase (B) Dihydrofolate reductase (C) Hypoxanthine guanine-phosphoribosyltransferase (HGPRT) (D) DNA polymerase
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['(B) Dihydrofolate reductase <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An investigator is studying intracellular processes in muscle tissue after denervation. A biopsy specimen is obtained from the biceps femoris muscle of an 82-year-old woman who sustained sciatic nerve injury. Investigation of the tissue specimen shows shrunken cells with dense eosinophilic cytoplasm, nuclear shrinkage, and plasma membrane blebbing. Which of the following best explains the muscle biopsy findings? (A) Release of mitochondrial cytochrome c (B) Degradation of Bcl-2-associated X protein (C) Denaturation of cytoplasmic proteins (D) Inhibition of Fas/FasL interaction
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['(A) Release of mitochondrial cytochrome c <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 48-year-old man with a 30-pack-year history comes to the physician for a follow-up examination 6 months after a chest CT showed a solitary 5-mm solid nodule in the upper lobe of the right lung. The follow-up CT shows that the size of the nodule has increased to 2 cm. Ipsilateral mediastinal lymph node involvement is noted. A biopsy of the pulmonary nodule shows small, dark blue tumor cells with hyperchromatic nuclei and scarce cytoplasm. Cranial MRI and skeletal scintigraphy show no evidence of other metastases. Which of the following is the most appropriate next step in management? (A) Wedge resection (B) Cisplatin-etoposide therapy and radiotherapy (C) Right lobectomy (D) Gefitinib therapy
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['(B) Cisplatin-etoposide therapy and radiotherapy <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 48-year-old man comes to the physician because of increasing generalized fatigue for 1 month. He has been unable to do normal household duties or go for his evening walks during this period. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. His father died of liver cancer at the age of 60 years. He does not smoke. He drinks one alcoholic beverage daily. Current medications include atorvastatin, enalapril, metformin, and insulin glargine. He is 170 cm (5 ft 7 in) tall and weighs 100 kg (220 lb); BMI is 34.6 kg/m2. His temperature is 36.6°C (97.9°F), pulse is 116/min, and blood pressure is 140/90 mm Hg. Examination shows hyperpigmented skin over the nape of the neck and extremities. The liver is palpated 4 cm below the right costal margin. Laboratory studies show: Hemoglobin 10.6 g/dL Mean corpuscular volume 87 μm3 Leukocyte count 9,700/mm3 Platelet count 182,000/mm3 Serum Glucose 213 mg/dL Creatinine 1.4 mg/dL Albumin 4.1 mg/dL Total bilirubin 1.1 mg/dL Alkaline phosphatase 66 U/L AST 100 U/L ALT 69 U/L γ-glutamyl transferase 28 U/L (N=5–50) Hepatitis B surface antigen negative Hepatitis C antibody negative Iron studies Iron 261 μg/dL Ferritin 558 ng/dL Transferrin saturation 83% Anti-nuclear antibody negative Which of the following is the most appropriate next step to confirm the diagnosis?" (A) CT of the abdomen (B) Abdominal ultrasonography (C) Liver biopsy (D) Genetic testing
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['(D) Genetic testing <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 73-year-old man noted a rapid onset of severe dizziness and difficulty swallowing while watching TV at home. His wife reports that he had difficulty forming sentences and his gait was unsteady at this time. Symptoms were severe within 1 minute and began to improve spontaneously after 10 minutes. He has had type 2 diabetes mellitus for 25 years and has a 50 pack-year smoking history. On arrival to the emergency department 35 minutes after the initial development of symptoms, his manifestations have largely resolved with the exception of a subtle nystagmus and ataxia. His blood pressure is 132/86 mm Hg, the heart rate is 84/min, and the respiratory rate is 15/min. After 45 minutes, his symptoms are completely resolved, and neurological examination is unremarkable. Which of the following is the most likely cause of this patient’s condition? (A) Vertebral artery occlusion (B) Middle cerebral artery occlusion (C) Posterior cerebral artery occlusion (D) Lenticulostriate artery occlusion
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['(A) Vertebral artery occlusion <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 63-year-old African American man presents to the emergency department with edema over his face and difficulty breathing. Past medical history is significant for hypertension and dyslipidemia. He recently began lisinopril and atorvastatin several weeks ago. His father died at 80 years from complications of a stroke and his mother lives in a nursing home. His blood pressure is 135/92 mm Hg, the heart rate is 101/min, the respiratory rate is 21/min, the temperature is 32.0°C (98.6°F). Clinical pathology results suggest a normal C1 esterase inhibitor level. Of the following options, which is the most likely diagnosis? (A) Scleredema (B) Erysipelas (C) Drug-induced angioedema (D) Contact dermatitis
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['(C) Drug-induced angioedema <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 2-week-old neonate in the intensive care unit presents as severely ill. His mother says he was a bit irritated earlier this week, and his condition deteriorated quickly. It is apparent that he is in constant pain. He could not be fed easily and vomited three times since yesterday alone. The physical examination is remarkable for a distended abdomen and diminished bowel sounds. The neonate is sent for an abdominal/chest X-ray, which shows substantial intraluminal gas affecting most of the bowel. The neonate was born at 32 weeks of gestation by a normal vaginal delivery. Which of the following is the best next step for this patient? (A) Hyperbaric oxygen (B) Epinephrine (C) Surgery (D) Surfactants
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['(C) Surgery <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A previously healthy 48-year-old man comes to the physician for a 3-month history of myalgias and recurrent episodes of retrosternal chest pain and dizziness. He has had a 5-kg (11-lb) weight loss during this period. His temperature is 39.1°C (102.3°F), pulse is 90/min, and blood pressure is 160/102 mm Hg. Physical examination shows lacy, purplish discoloration of the skin with multiple erythematous, tender subcutaneous nodules on the lower legs. Some of the nodules have central ulcerations. Serum studies show an erythrocyte sedimentation rate of 76 mg/dL and creatinine level of 1.8 mg/dL. Renal MR angiography shows irregular areas of dilation and constriction in the renal arteries bilaterally. Further evaluation of this patient is most likely to show which of the following? (A) Multinuclear giant cells with elastic membrane fragmentation on arterial biopsy (B) Transmural inflammation with fibrinoid necrosis on arterial biopsy (C) Pulmonary artery microaneurysms on pulmonary angiography (D) Presence of anti-myeloperoxidase antibodies in the serum
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['(B) Transmural inflammation with fibrinoid necrosis on arterial biopsy <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 42-year-old woman comes to the emergency department because of worsening severe pain, swelling, and stiffness in her right knee for the past 2 days. She recently started running 2 miles, 3 times a week in an attempt to lose weight. She has type 2 diabetes mellitus and osteoporosis. Her mother has rheumatoid arthritis. She drinks one to two glasses of wine daily. She is sexually active with multiple partners and uses condoms inconsistently. Current medications include metformin and alendronate. She is 161 cm (5 ft 3 in) tall and weighs 74 kg (163 lb); BMI is 29 kg/m2. Her temperature is 38.3°C (100.9°F), pulse is 74/min, and blood pressure is 115/76 mm Hg. She appears to be in discomfort and has trouble putting weight on the affected knee. Physical examination shows a 2-cm, painless ulcer on the plantar surface of the right toe. The right knee is swollen and tender to palpation. Arthrocentesis of the right knee with synovial fluid analysis shows a cell count of 55,000 WBC/μL with 77% polymorphonuclear (PMN) cells. Which of the following is the most likely underlying cause of this patient's presenting condition? (A) Autoimmune response to bacterial infection (B) Occult meniscal tear (C) Hematogenous spread of infection (D) Intra-articular deposition of urate crystals
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['(C) Hematogenous spread of infection <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 36-year-old man presents with soreness and dryness of the oral mucosa for the past 3 weeks. No significant past medical history. The patient reports that he has had multiple bisexual partners over the last year and only occasionally uses condoms. He denies any alcohol use or history of smoking. The patient is afebrile and his vital signs are within normal limits. On physical examination, there is a lesion noted in the oral cavity, which is shown in the exhibit. Which of the following is the next best step in the treatment of this patient? (A) Change the patient’s toothbrush and improve oral hygiene (B) Nystatin (C) Surgical excision (D) Topical corticosteroids
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['(A) Change the patient’s toothbrush and improve oral hygiene <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 57-year-old woman presents to her physician’s office because she is coughing up blood. She says that she first observed a somewhat reddish sputum a few months ago. However, over the past couple of weeks, the amount of blood she coughs has significantly increased. She has been smoking for the past 30 years. She says that she smokes about 2 packs of cigarettes daily. She does not have fever, night sweats, weight loss, or chills. She reports progressive difficulty in breathing. On examination, her vital signs are stable. On auscultation of her chest, she has an expiratory wheeze. Oxygen saturation is 98%. Which of the following would be the next best step in the management of this patient? (A) Chest radiograph (B) CT scan (C) Endoscopy (D) Bronchoscopy
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['(A) Chest radiograph <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An otherwise healthy 28-year-old primigravid woman at 30 weeks' gestation comes to the physician with a 5-day history of epigastric pain and nausea that is worse at night. Two years ago, she was diagnosed with a peptic ulcer and was treated with a proton pump inhibitor and antibiotics. Medications include folic acid and a multivitamin. Her pulse is 90/min and blood pressure is 130/85 mm Hg. Pelvic examination shows a uterus consistent in size with a 30-week gestation. Laboratory studies show: Hemoglobin 8.6 g/dL Platelet count 95,000/mm3 Serum Total bilirubin 1.5 mg/dL Aspartate aminotransferase 80 U/L Lactate dehydrogenase 705 U/L Urine pH 6.2 Protein 2+ WBC negative Bacteria occasional Nitrates negative Which of the following best explains this patient's symptoms?" (A) Bacterial infection of the kidney (B) Inflammation of the lower esophageal mucosa (C) Stretching of Glisson capsule (D) Acute inflammation of the pancreas
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['(C) Stretching of Glisson capsule <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 68-year-old man is brought to the emergency department because of fever, progressive weakness, and cough for the past five days. He experienced a similar episode 2 months ago, for which he was hospitalized for 10 days while visiting his son in Russia. He states that he has never fully recovered from that episode. He felt much better after being treated with antibiotics, but he still coughs often during meals. He sometimes also coughs up undigested food after eating. For the last 5 days, his coughing has become more frequent and productive of yellowish-green sputum. He takes hydrochlorothiazide for hypertension and pantoprazole for the retrosternal discomfort that he often experiences while eating. He has smoked half a pack of cigarettes daily for the last 30 years and drinks one shot of vodka every day. The patient appears thin. His temperature is 40.1°C (104.2°F), pulse is 118/min, respirations are 22/min, and blood pressure is 125/90 mm Hg. Auscultation of the lungs shows right basal crackles. There is dullness on percussion at the right lung base. The remainder of the physical examination shows no abnormalities. Laboratory studies show: Hemoglobin 15.4 g/dL Leukocyte count 17,000/mm3 Platelet count 350,000/mm3 Na+ 139 mEq/L K+ 4.6 mEq/L Cl- 102 mEq/L HCO3- 25 mEq/L Urea Nitrogen 16 mg/dL Creatinine 1.3 mg/dL An x-ray of the chest shows a right lower lobe infiltrate. Which of the following is the most likely explanation for this patient's symptoms?" (A) Weak tone of the lower esophageal sphincter (B) Formation of a tissue cavity containing necrotic debris (C) Uncoordinated contractions of the esophagus (D) Outpouching of the hypopharynx "
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['(D) Outpouching of the hypopharynx <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** An 82-year-old woman presents to the emergency department because of excruciating right flank pain and fever for the past 2 days. She states that she is having trouble urinating. Her past medical history is unremarkable. A urinalysis is performed and comes back positive for leukocytes and gram-negative bacilli. A contrast computed tomography of the abdomen is performed and reveals a large retroperitoneal mass compressing the right ureter, leading to hydronephrosis of the right kidney. The mass is excised. Histopathologic evaluation of the mass is shown in the image below, and it is determined to be malignant. Which of the following is the most likely diagnosis in this patient? (A) Liposarcoma (B) Rhabdomyosarcoma (C) Teratoma (D) Leiomyosarcoma
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['(A) Liposarcoma <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 71-year-old man comes to the emergency department because of pain and swelling in his left leg that started after he cut his foot while swimming in the ocean. He has a history of alcoholic cirrhosis. His temperature is 38.3°C (101.0°F). Examination of the left foot shows a small, purulent wound with surrounding swelling and dusky redness extending to the mid-calf. There are numerous hemorrhagic blisters and the entire lower leg is exquisitely tender to light palpation. There is no crepitus. Blood cultures grow gram-negative bacilli that ferment lactose. Which of the following is the most likely causal organism? (A) Shigella flexneri (B) Clostridium perfringens (C) Streptococcus pyogenes (D) Vibrio vulnificus
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['(D) Vibrio vulnificus <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 66-year-old man presents to the emergency department with a 3-hour history of crushing chest pain radiating to the left shoulder and neck. Patient states that the pain began suddenly when he was taking a walk around the block and has not improved with rest. He also mentions difficulty breathing and prefers to sit leaning forward. He denies ever having similar symptoms before. Past medical history is significant for hypertension, diagnosed 10 years ago, and hyperlipidemia diagnosed 8 years ago. Current medications are atorvastatin. Patient is also prescribed hydrochlorothiazide as an antihypertensive but is not compliant because he says it makes him urinate too often. Vitals show a blood pressure of 152/90 mm Hg, pulse of 106/min, respirations of 22/min and oxygen saturation of 97% on room air. On physical exam, patient is profusely diaphoretic and hunched over in distress. Cardiac exam is unremarkable and lungs are clear to auscultation. During your examination, the patient suddenly becomes unresponsive and a pulse cannot be palpated. A stat ECG shows the following (see image). Which of the following is the next best step in management? (A) Administer epinephrine (B) Synchronized cardioversion (C) Unsynchronized cardioversion (D) Urgent echocardiography
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['(C) Unsynchronized cardioversion <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 16-year-old male presents to his pediatrician with a sore throat. He reports a severely painful throat preceded by several days of malaise and fatigue. He has a history of seasonal allergies and asthma. The patient is a high school student and is on the school wrestling team. He takes cetirizine and albuterol. His temperature is 100.9°F (38.3°C), blood pressure is 100/70 mmHg, pulse is 100/min, and respirations are 20/min. Physical examination reveals splenomegaly and posterior cervical lymphadenopathy. Laboratory analysis reveals the following: Serum: Na+: 145 mEq/L K+: 4.0 mEq/L Cl-: 100 mEq/L HCO3-: 24 mEq/L BUN: 12 mg/dL Ca2+: 10.2 mg/dL Mg2+: 2.0 mEq/L Creatinine: 1.0 mg/dL Glucose: 77 mg/dL Hemoglobin: 17 g/dL Hematocrit: 47% Mean corpuscular volume: 90 µm3 Reticulocyte count: 1.0% Platelet count: 250,000/mm3 Leukocyte count: 13,000/mm3 Neutrophil: 45% Lymphocyte: 42% Monocyte: 12% Eosinophil: 1% Basophil: 0% Which of the following cell surface markers is bound by the pathogen responsible for this patient’s condition? (A) CD3 (B) CD4 (C) CD19 (D) CD21
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['(D) CD21 <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 42-year-old woman presents because of a painful mass she first noticed on her neck 1 week ago (see image). The mass has grown over the last few days. She has no history of serious illness and takes no medications. On physical exam, her temperature is 38.0°C (100.4°F), pulse is 86/min, respirations are 12/min, blood pressure is 135/80 mm Hg. The mass is tender and relatively soft and mobile. The overlying skin is warm. On her right ear, there is a series of small and healing skin punctures left by the bite of her neighbor’s kitten 3 weeks ago. No other mass is detected in the neck, supraclavicular, axillary, or inguinal regions. Oral examination reveals several discolored teeth. Her lungs are clear to auscultation and heart sounds are normal. Which of the following is the most appropriate diagnostic study at this time? (A) Culture for facultative anaerobes (B) Histologic evaluation for Reed-Sternburg cells (C) Toxoplasma IgG using enzyme-linked immunosorbent assay (D) Warthin-Starry silver stain for Bartonella henselae
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['(D) Warthin-Starry silver stain for Bartonella henselae <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 36-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of a gush of clear fluid from her vagina that occurred 1 hour prior. She reports painful pelvic cramping at regular 5-minute intervals. She has missed most of her prenatal care visit because of financial problems from her recent divorce. Her first child was delivered vaginally at 27 weeks' gestation due to spontaneous preterm labor. She has smoked one pack of cigarettes daily for 15 years but has reduced her intake to 2–3 cigarettes per day since finding out she was pregnant. She continues to use cocaine once a week. Vital signs are within normal limits. Sterile speculum examination shows fluid pooling in the vagina, and nitrazine paper testing confirms the presence of amniotic fluid. Which of the following puts her at highest risk of preterm delivery? (A) Low socioeconomic status (B) Smoking during pregnancy (C) Substance abuse during pregnancy (D) History of spontaneous preterm birth "
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['(D) History of spontaneous preterm birth <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 23-year-old woman, gravida 2, para 1, at 26 weeks gestation comes to the physician for a routine prenatal visit. Physical examination shows a uterus consistent in size with a 26-week gestation. Fetal ultrasonography shows a male fetus with a thick band constricting the right lower arm; the limb distal to the constrictive band cannot be visualized. The most likely condition is an example of which of the following embryological abnormalities? (A) Deformation (B) Agenesis (C) Disruption (D) Malformation
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['(C) Disruption <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 59-year-old man comes to the clinic for an annual well-exam. He was lost to follow-up for the past 3 years due to marital issues but reports that he feels fine. The patient reports, “I feel tired but it is probably because I am getting old. I do feel a little feverish today - I think I got a cold.” His past medical history is significant for hypertension that is controlled with hydrochlorothiazide. He reports fatigue, congestion, cough, and night sweats. He denies any sick contacts, recent travel, weight changes, chest pain, or dizziness. His temperature is 101°F (38.3°C), blood pressure is 151/98 mmHg, pulse is 97/min, and respirations are 15/min. His laboratory values are shown below: Hemoglobin: 13.5 g/dL Hematocrit: 41% Leukocyte count: 25,000/mm^3 Segmented neutrophils: 73% Bands: 8% Eosinophils: 1% Basophils: 2% Lymphocytes: 15% Monocytes: 2% Platelet count: 200,000/mm^3 What diagnostic test would be helpful in distinguishing this patient’s condition from pneumonia? (A) C-reactive protein (B) Erythrocyte sedimentation rate (C) Leukocyte alkaline phosphatase (D) Magnetic resonance imaging of the chest
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['(C) Leukocyte alkaline phosphatase <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 41-year-old male with a history of pneumocystis jiroveci pneumonia is found to have multiple ring-enhancing lesions on brain CT. Which of the following is most likely responsible for this patient's abnormal scan? (A) Neoplasm (B) Bacteria (C) Virus (D) Protozoa
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['(D) Protozoa <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 3-year-old girl presents to the emergency department with skin desquamation over her hips and buttocks and right arm; she also has conjunctivitis and fever. The patient was previously seen by her pediatrician for symptoms of impetigo around the nasal folds, and she was treated with topical fusidic acid. She was born at 39 weeks’ gestation via spontaneous vaginal delivery, is up to date on all vaccines, and is meeting all developmental milestones. Medical history and family history are unremarkable. She is admitted to the hospital and started on IV antibiotics. Today, her blood pressure is 100/60 mm Hg, heart rate is 100 beats per minute, respiratory rate is 22 breaths per minute, and temperature is 39.4°C (102.9°F). The total area of desquamation exceeds 20%, sparing the mucous membranes. She is transferred to the pediatric intensive care unit. What is the most likely cause of the disease? (A) Herpes simplex virus infection (B) Staphylococcus aureus infection (C) Bullous pemphigoid (D) Psoriasis
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['(B) Staphylococcus aureus infection <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 44-year-old woman comes to the physician because of a 6-month history of fatigue, constipation, and a 7-kg (15.4-lb) weight gain. Menses occur irregularly in intervals of 40–50 days. Her pulse is 51/min, and blood pressure is 145/86 mm Hg. Examination shows conjunctival pallor and cool, dry skin. There is mild, nonpitting periorbital edema. Serum thyroid-stimulating hormone concentration is 8.1 μU/mL. Treatment with the appropriate pharmacotherapy is initiated. After several weeks of therapy with this drug, which of the following hormonal changes is expected? (A) Decreased T4 (B) Increased reverse T3 (C) Increased thyroxine-binding globulin (D) Decreased T3
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['(B) Increased reverse T3 <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 57-year-old man presents to the emergency department with fatigue. He states that his symptoms started yesterday and have been worsening steadily. The patient endorses a recent weight loss of 7 pounds this past week and states that he feels diffusely itchy. The patient has a past medical history of alcohol abuse, obesity, asthma, and IV drug use. His current medications include metformin, atorvastatin, albuterol, and fluticasone. In addition, the patient admits to smoking and drinking more than usual lately due to the stress he has experienced. His temperature is 98.7°F (37.1°C), blood pressure is 130/75 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for an ill-appearing man. The patient's skin appears yellow. Abdominal exam is notable for right upper quadrant tenderness. Cardiac and pulmonary exams are within normal limits. Laboratory values are ordered as seen below: Hemoglobin: 14 g/dL Hematocrit: 42% Leukocyte count: 5,500 cells/mm^3 with normal differential Platelet count: 70,000/mm^3 Partial thromboplastin time: 92 seconds Prothrombin time: 42 seconds AST: 1110 U/L ALT: 990 U/L Which of the following is most likely to be found in this patient's history? (A) Appropriate acute management of a deep vein thrombosis (B) Prosthetic valve with appropriate post-operative care (C) Recent antibiotic treatment with gentamicin (D) Severe migraine headaches treated with acetaminophen
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['(D) Severe migraine headaches treated with acetaminophen <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 2-year-old girl is brought to the emergency department after swallowing a button battery that was lying on the table 1 hour ago. She has no shortness of breath or chest discomfort. Her pulse is 112/min and respirations are 30/min. Pulse oximetry on room air shows an oxygen saturation of 98%. Physical examination shows no abnormalities. An x-ray of the chest shows the battery lodged in the esophagus at the level of T2. Which of the following is the most appropriate next step in management? (A) Administer syrup of ipecac (B) Reassurance and observation (C) Administer chelation therapy (D) Endoscopic removal of the battery
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['(D) Endoscopic removal of the battery <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 78-year-old woman comes to the physician because of a 2-month history of right-sided headache and generalized fatigue. She also has pain, weakness, and stiffness of her shoulders and hips. The stiffness is worse in the morning and usually improves after 60–90 minutes of activity. Three months ago, she fell and hit her head on the kitchen countertop. Her temperature is 38.1°C (100.6°F). Examination shows normal muscle strength in bilateral upper and lower extremities; range of motion of the shoulder and hip is mildly limited by pain. Deep tendon reflexes are 2+ bilaterally. Her erythrocyte sedimentation rate is 68 mm/h and serum creatine kinase is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's headache? (A) Tension headache (B) Large-vessel vasculitis (C) Hyperthyroidism (D) Cluster headache
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['(B) Large-vessel vasculitis <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 32-year-old man comes to the physician for a follow-up examination. He has a 2-month history of increasing generalized fatigue and severe pruritus. He has hypertension and ulcerative colitis which was diagnosed via colonoscopy 5 years ago. Current medications include lisinopril and rectal mesalamine. He is sexually active with 2 female partners and uses condoms inconsistently. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 130/84 mm Hg. Examination shows scleral icterus and multiple scratch marks on the trunk and extremities. The lungs are clear to auscultation. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 11.5 g/dL Leukocyte count 7500/mm3 Platelet count 280,000/mm3 Serum Na+ 138 mEq/L Cl- 101 mEq/L K+ 4.7 mEq/L Urea nitrogen 18 mg/dL Glucose 91 mg/dL Creatinine 0.8 mg/dL Bilirubin Total 1.5 mg/dL Direct 0.9 mg/dL Alkaline phosphatase 460 U/L AST 75 U/L ALT 78 U/L Anti-nuclear antibody negative Antimitochondrial antibodies negative Abdominal ultrasound shows thickening of the bile ducts and focal bile duct dilatation. Which of the following is the most likely diagnosis?" (A) Autoimmune hepatitis (B) Primary sclerosing cholangitis (C) Hepatitis B infection (D) IgG4-associated cholangitis
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['(B) Primary sclerosing cholangitis <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 62-year-old man presents with multiple episodes of hemoptysis for a week. It is associated with generalized weakness, decreased appetite, and a 5.4 kg (12 lb) weight loss in 2 months. He has a smoking history of a pack a day for the last 47 years. Physical examination reveals pallor, while the rest of the results are within normal limits. Laboratory studies reveal decreased hemoglobin and a serum sodium value of 130 mEq/L. Chest X-ray shows a 3 cm rounded opaque shadow. Which of the following conditions is the patient most likely suffering from? (A) Tuberculoma (B) Small cell carcinoma of the lung (C) Squamous cell carcinoma of the lung (D) Adenocarcinoma of the lung
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['(B) Small cell carcinoma of the lung <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient? (A) Urgent cesarean delivery (B) Admit for maternal and fetal monitoring and observation (C) Corticosteroid administration and schedule a cesarean section after (D) Manage as an outpatient with modified rest
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['(B) Admit for maternal and fetal monitoring and observation <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 52-year-old female presents to her rheumatologist with complaints of fatigue, a sore mouth, and occasional nausea and abdominal pain over the past several months. Her medical history is significant for 'pre-diabetes' treated with diet and exercise, hypertension managed with lisinopril, and rheumatoid arthritis well-controlled with methotrexate. Her vital signs are within normal limits. Physical examination is significant for an overweight female with the findings as shown in Figures A and B. The physician orders laboratory work-up including complete blood count with peripheral blood smear as well as basic metabolic panel and serum methylmalonic acid and homocysteine levels. These tests are significant for a hematocrit of 29.5, a decreased reticulocyte count, normal serum methylmalonic acid level, increased homocysteine level, as well as the peripheral smear shown in Figure C. Which of the following could have reduced this patient's risk of developing their presenting condition? (A) Discontinuation of lisinopril and initiation of triamterene for blood pressure control (B) Administration of daily, high-dose PO vitamin B12 (C) Initiation of folinic acid (D) Addition of metformin
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['(C) Initiation of folinic acid <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 36-year-old G4P0A3 woman presents at the prenatal diagnostic center at 18 weeks of gestation for the scheduled fetal anomaly scan. The patient's past medical history reveals spontaneous abortions. She reports that her 1st, 2nd, and 3rd pregnancy losses occurred at 8, 10, and 12 weeks of gestation, respectively. Ultrasonography indicates a female fetus with cystic hygroma (measuring 4 cm x 5 cm in size) and fetal hydrops. Which of the following karyotypes does her fetus most likely carry? (A) Trisomy 21 (B) Monosomy 18 (C) Trisomy 13 (D) 45 X0
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['(D) 45 X0 <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 10-day-old male newborn is brought to the physician by his mother because of difficulty feeding and frequent nonbilious vomiting. His stool is soft and yellow-colored. The pregnancy was complicated by polyhydramnios and results from chorionic villus sampling showed a 47, XY, +21 karyotype. Physical examination shows mild abdominal distention and normal bowel sounds. An x-ray of the abdomen with oral contrast is shown. The most likely cause of his condition is due to a defect in which of the following embryologic processes? (A) Rotation of the ventral pancreatic bud (B) Foregut septation (C) Ganglion cell migration (D) Umbilical ring closure
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['(A) Rotation of the ventral pancreatic bud <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 52-year-old woman comes to the emergency department because of a 3-hour history of right flank pain and nausea. Her only medication is a multivitamin. Her vital signs are within normal limits. Physical examination shows tenderness in the right costovertebral angle. Urinalysis shows a pH of 5.1, 50–60 RBC/hpf, and dumbbell-shaped crystals. Which of the following best describes the composition of the crystals seen on urinalysis? (A) Magnesium ammonium phosphate (B) Calcium oxalate (C) Cystine (D) Ammonium urate
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['(B) Calcium oxalate <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 59-year-old woman presents to her primary care physician for trouble sleeping. The patient states that when she goes to bed at night she has an urge to get up out of bed and walk around. The patient often wakes her husband when she does this which irritates him. She states that there is a perpetual uneasiness and feeling of a need to move at night which is relieved by getting up and walking around. The patient denies symptoms during the day. She works as a mail carrier and is nearing retirement. She has a past medical history of anxiety, depression, irritable bowel syndrome, and dysmenorrhea. She is not currently taking any medications. Her temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam reveals 5/5 strength in the upper and lower extremities, 2+ reflexes in the upper and lower extremities, a stable gait pattern, and normal sensation. Cardiopulmonary and abdominal exams are within normal limits. Which of the following is the best initial step in management? (A) Alprazolam (B) Ferrous sulfate (C) Iron studies (D) Pramipexole
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['(C) Iron studies <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 75-year-old man with a seizure disorder is brought to the emergency department by a friend because of progressive confusion over the past two weeks. He is unable to provide any history. His vital signs are within normal limits. He appears lethargic and is only oriented to person. Oral mucosa is moist. There is no jugular venous distention. A basic metabolic panel shows a serum sodium concentration of 115 mEq/L but is otherwise normal. Serum osmolality is low and antidiuretic hormone level is elevated. X-ray of the chest shows no abnormalities. Which of the following is the most likely cause of this patient’s hyponatremia? (A) Insulin deficiency (B) Aldosterone deficiency (C) Medication effect (D) Excess cortisol
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['(C) Medication effect <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 16-year-old boy is brought to the physician by his parents because of a 6-month history of progressive fatigue and worsening shortness of breath on exertion. The parents report that the boy “has always been tired out a bit more easily than other kids.” The family recently immigrated to the United States from rural South Korea. Pulse oximetry on room air shows an oxygen saturation of 96% on bilateral index fingers. Radial pulses are bounding. There is mild bluish discoloration and bulbous enlargement of the distal toes bilaterally. Echocardiography is most likely to show which of the following? (A) Single overriding great vessel arising from the heart (B) Persistent blood flow between the pulmonary artery and descending aorta (C) Positioning of the ascending aorta directly over a ventricular septal defect (D) Abnormal narrowing of the aorta at the aortic isthmus
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['(B) Persistent blood flow between the pulmonary artery and descending aorta <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 58-year-old man presents to the clinic concerned about his health after his elder brother recently became bed-bound due to a brain condition. He has also brought a head CT scan of his brother to reference, as shown in the picture. The patient has type 2 diabetes mellitus, hypertension, osteoarthritis, and hypercholesterolemia. His medication list includes aspirin, diclofenac sodium, metformin, and ramipril. He leads a sedentary lifestyle and smokes one pack of cigarettes daily. He also drinks 4–5 cups of red wine every weekend. His BMI is 33.2 kg/m2. His blood pressure is 164/96 mm Hg, the heart rate is 84/min, and the respiratory rate is 16/min. Which of the following interventions will be most beneficial for reducing the risk of developing the disease that his brother has? (A) Blood pressure control (B) Quit smoking (C) Take statins (D) Stop aspirin
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['(A) Blood pressure control <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 27-year-old pregnant woman presents to an obstetrician at 35 weeks gestation reporting that she noted the presence of a mucus plug in her vaginal discharge this morning. The obstetrician performs an examination and confirms that she is in labor. She was diagnosed with HIV infection 1 year ago. Her current antiretroviral therapy includes abacavir, lamivudine, and nevirapine. Her last HIV RNA level was 2,000 copies/mL 3 weeks ago. Which of the following anti-retroviral drugs should be administered intravenously to the woman during labor? (A) Enfuvirtide (B) Nevirapine (C) Rilpivirine (D) Zidovudine
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['(D) Zidovudine <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 32-year-old woman comes to the physician because of a 6-week history of fatigue and weakness. Examination shows marked pallor of the conjunctivae. The spleen tip is palpated 2 cm below the left costal margin. Her hemoglobin concentration is 9.5 g/dL, serum lactate dehydrogenase concentration is 750 IU/L, and her serum haptoglobin is undetectable. A peripheral blood smear shows multiple spherocytes. When anti-IgG antibodies are added to a sample of the patient's blood, there is clumping of the red blood cells. Which of the following is the most likely predisposing factor for this patient's condition? (A) Hereditary spectrin defect (B) Bicuspid aortic valve (C) Mycoplasma pneumoniae infection (D) Systemic lupus erythematosus
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['(D) Systemic lupus erythematosus <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 29-year-old woman comes to the emergency room with a 4-day history of fever and worsening cough. She describes bringing up a purulent, yellow sputum when she coughs. The patient has a history of cystic fibrosis and works as an elementary school teacher. The patient’s temperature is 102.3°F (39.1°C), blood pressure is 113/73 mmHg, pulse is 98/min, respirations are 18/min, and oxygen saturation is 94% on room air. She is sitting up in bed and sweating. Physical exam reveals bilateral crackles and decreased breath sounds with a dullness to percussion in the right lung base. A chest radiograph is obtained and reveals a right lower lobe pneumonia. Which of the following is the most likely agent? (A) Haemophilus influenzae (B) Pseudomonas aeruginosa (C) Staphylococcus aureus (D) Streptococcus pneumoniae
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['(B) Pseudomonas aeruginosa <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 62-year-old man presents with “yellowing” of the skin. He says he has been having intermittent upper abdominal pain, which is relieved by Tylenol. He also recalls that he has lost some weight over the past several months but can not quantify the amount. His past medical history is significant for type 2 diabetes mellitus. He reports a 40-pack-year smoking history. The patient is afebrile and vital signs are within normal limits. Physical examination reveals mild jaundice and a palpable gallbladder. Laboratory findings are significant for the following: Total bilirubin 13 mg/dL Direct bilirubin: 10 mg/dL Alkaline phosphatase (ALP): 560 IU/L An ultrasound of the abdomen reveals a hypoechoic mass in the epigastric region. The patient is scheduled for a CT abdomen and pelvis with specific organ protocol for further evaluation. Which of the following best describes this patient’s most likely diagnosis? (A) Caffeine consumption is an established risk factor for this condition. (B) The majority of cases occur in the body of the pancreas. (C) Patients with this condition often rapidly develop glucose intolerance and severe diabetes. (D) CA 19-9 is a marker for this condition.
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['(D) CA 19-9 is a marker for this condition. <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 36-year-old man comes to the physician for a 4-week history of swollen legs. He has difficulty putting on socks because of the swelling. Two years ago, he was diagnosed with sleep apnea. He takes no medications. He emigrated from Guatemala with his family when he was a child. He is 171 cm (5 ft 6 in) tall and weighs 115 kg (253 lb); BMI is 39 kg/m2. His pulse is 91/min and blood pressure is 135/82 mm Hg. Examination shows periorbital and bilateral lower extremity edema. Serum Albumin 3.1 g/dL Total cholesterol 312 mg/dL Urine Blood negative Protein +4 RBC 1-2/hpf RBC cast negative Fatty casts numerous A renal biopsy is obtained. Which of the following is most likely to be seen under light microscopy of the patient's renal biopsy specimen?" (A) Segmental sclerosis of the glomeruli (B) Fibrin crescents within the glomerular space (C) Diffuse thickening of glomerular capillaries (D) Amyloid deposition in the mesangium
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['(A) Segmental sclerosis of the glomeruli <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 70-year-old man is accompanied by his wife to the primary care clinic for hand tremors. He states that he first noticed the tremor of his left hand 1 year ago. Since then, the tremor has been worsening and now he can hardly relax when trying to read. His wife says that she is also worried about his memory. She had to take over the finances several weeks ago after learning that he had forgotten to pay the bills for the past few months. The patient’s medical history is significant for hypertension. He takes aspirin and amlodipine. His mother had schizophrenia. The patient drinks 1-2 beers a night and is a former cigar smoker. On physical examination, he speaks softly and has reduced facial expressions. He has a resting tremor that is worse on the left, and he resists manipulation of his bilateral upper extremities. Which of the following is the most likely diagnosis? (A) Essential tremor (B) Parkinson disease (C) Progressive supranuclear palsy (D) Tardive dyskinesia
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['(B) Parkinson disease <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 64-year-old woman has progressively worsening abdominal pain 5 hours after an open valve replacement with cardiopulmonary bypass. The pain is crampy and associated with an urge to defecate. The patient reports having had 2 bloody bowel movements in the last hour. Her operation was complicated by significant intraoperative blood loss, which prolonged the operation and necessitated 2 transfusions of red blood cells. She has hypercholesterolemia and type 2 diabetes mellitus. The patient received prophylactic perioperative antibiotics and opioid pain management during recovery. Her temperature is 37.9°C (98.9°F), pulse is 95/min, and blood pressure is 115/69 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the left quadrants but no rebound tenderness or guarding. Bowel sounds are decreased. Rectal examination shows blood on the examining finger. Which of the following is the most likely underlying cause of this patient's symptoms? (A) Decreased blood flow to the splenic flexure (B) Small outpouchings in the sigmoid wall (C) Atherosclerotic narrowing of the intestinal vessels (D) Infection with Clostridioides difficile
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['(A) Decreased blood flow to the splenic flexure <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 28-year-old woman presents with a malodorous vaginal discharge and itchiness that have lasted for 15 days. She reports that the smell of the discharge is worse after intercourse and is accompanied by a whitish-gray fluid. She has no significant past medical or gynecological history. She is in a stable monogamous relationship and has never been pregnant. She is diagnosed with bacterial vaginosis and prescribed an antimicrobial agent. Which of the following diagnostic features is consistent with this patient’s condition? (A) Vaginal fluid pH > 5.0, motile flagellated pyriform protozoa seen on the microscopic examination of the vaginal secretions (B) Vaginal fluid pH > 4.5, clue cells present on a saline smear of the vaginal secretions, along with a fishy odor on addition of KOH (C) Vaginal fluid pH > 4.0, hyphae on the microscopic examination of the vaginal secretions after the addition of KOH (D) Vaginal fluid pH > 6.0, scant vaginal secretions, increased parabasal cells
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['(B) Vaginal fluid pH > 4.5, clue cells present on a saline smear of the vaginal secretions, along with a fishy odor on addition of KOH <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 54-year-old man was brought to the emergency room due to acute onset of slurred speech while at work, after which he lost consciousness. The patient’s wife says this occurred approximately 30 minutes ago. Past medical history is significant for poorly controlled hypertension and type 2 diabetes mellitus. His blood pressure is 90/50 mm Hg, respiratory rate is 12/min, and heart rate is 48/min. The patient passes away shortly after arriving at the hospital. At autopsy, bilateral wedge-shaped strips of necrosis are seen in this patient’s brain just below the medial temporal lobes. Which of the following is the most likely location of these necrotic cells? (A) Hippocampus (B) Caudate nucleus (C) Cortex or cerebral hemisphere (D) Substantia nigra
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['(A) Hippocampus <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 51-year-old man is undergoing chemotherapy treatment for a rapidly progressive newly-diagnosed acute myelogenous leukemia. On day 4 of his hospitalization, the patient is noted to be obtunded. Other than the chemotherapy, he is receiving lansoprazole, acetaminophen, and an infusion of D5–0.9% normal saline at 50 mL/h. On examination, the patient’s blood pressure is 94/50 mm Hg, heart rate is 52/min, and respiratory rate is 14/min. The patient appears weak but is in no acute distress. Chest auscultation reveals bibasilar crackles and scattered wheezing. His abdomen is soft, non-distended, and with a palpable liver and spleen. His ECG shows peaked T waves and widened QRS complexes. What is the best next step in the management of this patient? (A) Glucagon (B) Subcutaneous regular insulin (C) Polystyrene sulfonate (D) Calcium chloride
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['(D) Calcium chloride <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 45-year-old man is brought to the emergency department because of a 1-day history of malaise and abdominal pain. Six weeks ago, he had vomiting and watery diarrhea for 2 days that resolved without treatment. Twelve weeks ago, he underwent orthotopic liver transplantation for alcoholic cirrhosis. At the time of discharge, his total serum bilirubin concentration was 1.0 mg/dL. He stopped drinking alcohol one year ago. His current medications include daily tacrolimus, prednisone, valganciclovir, and trimethoprim-sulfamethoxazole. His temperature is 37.7°C (99.9°F), pulse is 95/min, and blood pressure is 150/80 mm Hg. He appears uncomfortable and has mild jaundice. Examination shows scleral icterus. The abdomen is soft and tender to deep palpation over the right upper quadrant, where there is a well-healed surgical scar. His leukocyte count is 2500/mm3, serum bilirubin concentration is 2.6 mg/dL, and serum tacrolimus concentration is within therapeutic range. Which of the following is the next appropriate step in diagnosis? (A) CT scan of the abdomen with contrast (B) Viral loads (C) Esophagogastroduodenoscopy (D) Ultrasound of the liver
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['(D) Ultrasound of the liver <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 61-year-old female with congestive heart failure and type 2 diabetes is brought to the emergency room by her husband because of an altered mental status. He states he normally helps her be compliant with her medications, but he had been away for several days. On physical exam, her temperature is 37.2 C, BP 85/55, and HR 130. Serum glucose is 500 mg/dL. Which of the following is the first step in the management of this patient? (A) IV ½ NS (B) IV NS (C) IV D5W (D) IV insulin
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['(B) IV NS <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 75-year-old female patient comes to the emergency department with altered mental status. She is brought in by her daughter with whom the patient lives. The patient’s daughter said they were watching TV when her mother became unresponsive. On exam the patient withdraws to pain but does not open her eyes or speak. An emergent head CT is done and shows an intracranial bleed. The patient is moved to the ICU and intubated. Further history is obtained from the daughter. The patient has a past medical history of diabetes and a previous stroke. Her medications are metformin and warfarin. The patient is compliant with all of her medications. The daughter says that the patient changed her diet about 1 month ago in response to a diet she saw on a talk show. Which of the following foods is most likely to cause the pathology seen in this patient? (A) St. John’s wort (B) Chili peppers (C) Grapefruit juice (D) Spinach
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['(C) Grapefruit juice <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 32-year-old woman presents to a psychiatrist to discuss a recent event in her life. At a social function 2 days back, she met a man who introduced himself as having worked with her at another private company 3 years ago. However, she did not recognize him. She also says that she does not remember working at any such company at any time during her life. However, the patient’s husband says that she had indeed worked at that company for three months and had quit due to her boss’s abusive behavior towards her. The man who met her at the function had actually been her colleague at that job. The woman asks the doctor, “How is it possible? I am really not able to recall any memories of having worked at any such company. What’s going on here?”. Her husband adds that after she quit the job, her mood frequently has been low. The patient denies any crying episodes, suicidal ideas, not enjoying recreational activities or feelings of worthlessness. Her appetite and sleep patterns are normal. She is otherwise a healthy woman with no significant medical history and lives a normal social and occupational life. The patient reports no history of smoking, alcohol, or substance use. On physical examination, she is alert and well-oriented to time, place and person. During memory testing, she correctly remembers the date of her marriage that took place 5 years back and the food she ate over the last 2 days. Which of the following is the most likely diagnosis in this patient? (A) Pseudodementia (B) Dissociative amnesia (C) Dissociative identity disorder (D) Transient global amnesia
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['(B) Dissociative amnesia <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 28-year-old woman with HIV comes to the physician because of an 8-day history of severe pain while swallowing. She has been hospitalized several times with opportunistic infections and has poor adherence to her antiretroviral drug regimen. Endoscopy shows extensive, white, plaque-like lesions in the proximal esophagus. Culture of a biopsy specimen grows Candida albicans. Treatment with intravenous anidulafungin is initiated. Which of the following is the primary mechanism of action of this drug? (A) Decreased DNA synthesis (B) Binding to tubulin (C) Decreased glucan synthesis (D) Inhibition of squalene epoxidase
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['(C) Decreased glucan synthesis <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 70 year-old man comes to the emergency department for sudden loss of vision in the right eye over the last 24 hours. He has noticed progressive bilateral loss of central vision over the last year. He has had difficulty reading his newspaper and watching his television. He has smoked 1 pack daily for 50 years. Ophthalmologic examination shows visual acuity of 20/60 in the left eye and 20/200 in the right eye. The pupils are equal and reactive to light. Tonometry reveals an intraocular pressure of 18 mm Hg in the right eye and 20 mm Hg in the left eye. Anterior segment exam is unremarkable. Slit-lamp examination shows subretinal fluid and small hemorrhage with grayish-green discoloration in the macular area in the right eye, and multiple drusen in the left eye with retinal pigment epithelial changes. Which of the following is the most appropriate initial treatment for the patient's illness? (A) Etanercept (B) Thermal laser photocoagulation (C) Ranibizumab (D) Macular translocation surgery
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['(C) Ranibizumab <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** Two-hours into recovery from general anesthesia for an orthopedic fracture, a 34-year-old woman develops fever and masseter muscle rigidity with lockjaw. She has no history of a similar episode. She has no history of serious illness and takes no medications. She appears confused. In the recovery room, her blood pressure is 78/50 mm Hg, the pulse is 128/min, the respirations are 42/min, and the temperature is 40.3°C (104.5°F). Cardiopulmonary examination shows no abnormalities. Laboratory studies show: Serum Na+ 145 mEq/L K+ 6.5 mEq/L Arterial blood gas on room air pH 7.01 PCO2 78 mm Hg HCO3− 14 mEq/L PO2 55 mm Hg The patient is reintubated. Which of the following is the most appropriate next step in pharmacotherapy? (A) Cyproheptadine (B) Dantrolene (C) Labetalol (D) Lorazepam
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['(B) Dantrolene <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 38-year-old woman comes to the physician because of frequent headaches and blurring of vision. She also complains of weight gain, menstrual irregularities, and excessive growth of body hair. She says that, for the first time since she turned 18, her shoe and ring sizes have increased, and also complains that her voice has become hoarser. She does not smoke or drink alcohol. She takes no medications. Vital signs are within normal limits. Physical examination shows prominent frontal bossing, a protuberant mandible with spaces between the teeth, and large hands and feet. Serum studies show: Na+ 140 mEq/L Cl− 102 mEq/L K+ 4.1 mEq/L Ca2+ 10.6 mg/dL Phosphorus 4.7 mg/dL Glucose 180 mg/dL Which of the following is the most likely sequela of this patient's condition?" (A) Deposition of mucopolysaccharides in the myocardium (B) Thickening of the coronary artery walls (C) Prolongation of the QT interval on ECG (D) Reduced cardiac output
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['(D) Reduced cardiac output <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 27-year-old Hispanic G2P1 presents for a routine antepartum visit at 26 weeks gestation. She has no complaints. The vital signs are normal, the physical examination is within normal limits, and the gynecologic examination corresponds to 25 weeks gestation. The oral glucose tolerance test (OGTT) with a 75-g glucose load is significant for a glucose level of 177 mg/dL at 1 hour and 167 mg/dL at 2 hour. The fasting blood glucose level is 138 mg/dL (7.7 mmol/L), and the HbA1c is 7%. Which of the following represents the proper initial management? (A) Dietary and lifestyle modification (B) Insulin (C) Glyburide (D) Sitagliptin
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['(A) Dietary and lifestyle modification <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 47-year-old woman comes to the physician because of a 2-week history of gradually worsening facial and lower extremity swelling. She has had a 4-kg (8.8-lb) weight gain during this time. Her blood pressure is 150/88 mm Hg. Examination shows periorbital edema and 2+ pretibial edema bilaterally. A 24-hour collection of urine shows 4.0 g of proteinuria. Microscopic examination of a kidney biopsy specimen shows thickening of the glomerular basement membrane. Electron microscopy shows dense subepithelial deposits. Further evaluation is most likely to show which of the following? (A) Anti-phospholipase A2 receptor antibodies (B) Anti-myeloperoxidase antibodies (C) Anti-streptolysin O antibodies (D) Anti-collagen type IV antibodies
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['(A) Anti-phospholipase A2 receptor antibodies <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 19-year-old man presents with painful oral ulcers and rash. He says that his symptoms started 1 week ago with a low-grade fever, malaise, and cough. Then, 3 days ago, he noted small painful red bumps on his hands and feet, which quickly worsened and spread to involve his extremities and upper torso. At the same time, multiple painful oral ulcers appeared, which have not improved. He denies any trouble breathing, pruritus, hemoptysis, hematochezia, or similar symptoms in the past. Past medical history is significant for a recent methicillin-resistant staphylococcus aureus (MRSA) skin infection 2 weeks ago secondary to a laceration on his left leg for which he has been taking trimethoprim-sulfamethoxazole. No other current medications. The patient is afebrile, and his vital signs are within normal limits. Physical examination reveals multiple raised, erythematous, circular papules averaging 1–2 cm in diameter with a central bulla, as shown in the exhibit (see image below). The cutaneous lesions occupy < 10% of his total body surface area (BSA). Nicolsky sign is negative. Multiple mucosal erosions are noted in the oral cavity. Generalized lymphadenopathy is present. A well-healing laceration is present on the left leg with no evidence of drainage or fluctuance. A cutaneous punch biopsy of one of the lesions is performed. Which of the following histopathologic features would most likely be found on this patient’s biopsy? (A) Scant dermal inflammatory infiltrate, predominantly composed of macrophages and dendritic cells (B) Rich dermal inflammatory infiltrate, predominantly composed of CD4+ T cells (C) Presence of a subepidermal blister and a polymorphous inflammatory infiltrate with an eosinophilic predominance (D) Mucin deposition in the dermal layer
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['(B) Rich dermal inflammatory infiltrate, predominantly composed of CD4+ T cells <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 57-year-old man is brought to the emergency department 2 hours after the onset of severe nausea and vomiting. He also has cramping abdominal pain and feels fatigued. Two months ago, he injured his lumbar spine in a car accident and lost complete motor and sensory function below the level of injury. He has been bedridden ever since and is cared for at home. He has type 2 diabetes mellitus and renal insufficiency. Examination shows dry mucosal membranes and sensory impairment with flaccid paralysis in both lower limbs that is consistent with prior examinations. Laboratory studies show: Serum Calcium 12.8 mg/dL Parathyroid hormone, N-terminal 180 pg/mL Thyroid-stimulating hormone 2.5 μU/mL Thyroxine 8 μg/dL Calcitriol Decreased Creatinine 2.6 mg/dL Urine Calcium 550 mg/24 h In addition to administration of intravenous 0.9% saline and calcitonin, which of the following is the most appropriate next step in management?" (A) Reduced calcium intake (B) Hemodialysis (C) Bisphosphonates (D) Glucocorticoids
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['(C) Bisphosphonates <> answer']
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The following are multiple choice questions (with answers) about medical knowledge. **Question:** A 25-year-old woman is rushed to the emergency department after she was found unconscious in a house fire. She has no previous medical history available. At the hospital, the vital signs include: blood pressure 110/70 mm Hg, temperature 36.0°C (97.0°F), and heart rate 76/min with oxygen saturation 99% on room air. On physical exam she is unconscious. There are superficial burns on her hands and parts of her face. Her face and clothes are blackened with soot. What is the 1st best step while treating this patient? (A) Penicillamine (B) Sodium nitrite (C) Administer 100% oxygen (D) Pyridoxine (vitamin B6)
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['(C) Administer 100% oxygen <> answer']
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