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A 68-year-old woman presents to the emergency room with several days of frequent, nonbloody, watery stools. She recently completed a course of clindamycin 2 weeks ago for a tooth infection. Her medical history is notable for hypertension and hyperlipidemia for which she takes amlodipine and atorvastatin. She traveled recently and has no sick contacts. Her temperature is 37.0°C (98.6°F), blood pressure is 118/82 mmHg, pulse is 98/min, respirations are 14/min, and oxygen saturation is 98% on room air. On exam, her abdomen is soft, non-distended, and non-tender to palpation; however she has diffuse discomfort upon palpation of the abdomen with no rebound, rigidity, or guarding. Which of the following is most likely to confirm the diagnosis? | {
"A": "Abdominal radiograph",
"B": "CT imaging of abdomen and pelvis",
"C": "Flexible sigmoidoscopy",
"D": "Rectal swab for selective anaerobic culture",
"E": "Stool toxin assay"
} | Stool toxin assay | E |
A 21-year-old woman presents to her primary care physician due to a history of abdominal pain. She states that she has had recurrent bouts of mood swings, bloating, and abdominal pain that occur together approximately every 4 weeks. She states that when these symptoms occur, she gets into frequent arguments at work, is unable to concentrate, and sleeps longer than usual. Furthermore, she has episodes of extreme anxiety during these periods, leading her to take off time from work. She notes that these symptoms are causing distress in her interpersonal relationships as well. She has no past medical history and takes no medications. She experienced menarche at age 12 and has regular periods. Her temperature is 98.2°F (36.8°C), blood pressure is 100/70 mmHg, pulse is 75/min, and respirations are 12/min. Physical exam reveals a nontender abdomen. Pelvic exam reveals a closed cervix with no cervical motion or adnexal tenderness. Her cardiopulmonary and neurological exams are unremarkable. Which of the following is the most likely diagnosis? | {
"A": "Generalized anxiety disorder",
"B": "Major depressive disorder",
"C": "Panic disorder",
"D": "Premenstrual dysophoric disorder",
"E": "Premenstrual syndrome"
} | Premenstrual dysophoric disorder | D |
A 15-year-old girl presents to the clinic due to concern that she may be pregnant. She had unprotected sexual intercourse earlier that morning and requests emergency contraception. She has had regular menses since menarche, and her last menstrual period ended 8 days ago. She has no significant medical history. Her temperature is 98.6°F (37°C), blood pressure is 114/71 mmHg, pulse is 81/min, and respirations are 12/min. A physical exam is unremarkable. A urine pregnancy test is negative. The patient asks for an emergency contraceptive pill and would prefer that her parents not be notified about her visit. In most states, which of the following is the most appropriate next step in the management for this patient? | {
"A": "Do not prescribe emergency contraception given that the patient is under 18 years old",
"B": "Obtain parental consent before providing emergency contraception",
"C": "Prescribe high-dose oral contraceptives",
"D": "Prescribe levonorgestrel pill",
"E": "Prescribe misoprostol pill"
} | Prescribe levonorgestrel pill | D |
A 65-year-old woman presents to her family doctor to reestablish care since losing her insurance. She has not had time for regular check-ups. She exercises 3-4 times a week and consumes red meat sparingly. She drank and smoked cigarettes socially with coworkers but never at home or on vacation. She wakes up with achy wrists and elbows that she suspects is from years of using a computer keyboard. She completed menopause at age 52. Her family history is notable for coronary artery disease on her father's side and colon cancer on her mother's side. She last had a colonoscopy 5 years ago that revealed no abnormal findings. Her temperature is 99°F (37.2°C), blood pressure is 125/83 mmHg, pulse is 82/min, respirations are 12/min, and oxygen saturation is 99% on room air. Her physical exam is grossly unremarkable. What diagnostic test should this patient receive? | {
"A": "Chest radiograph",
"B": "Colonoscopy",
"C": "Mammography",
"D": "Pelvic ultrasound",
"E": "Vitamin D level"
} | Mammography | C |
A 27-year-old man presents to the emergency department with altered mental status. He was running a marathon but became confused halfway through the race. He arrives unable to coherently answer questions and is not sure where he is. He has a history of a seizure disorder. His temperature is 105°F (40.6°C), blood pressure is 116/68 mmHg, pulse is 167/min, respirations are 29/min, and oxygen saturation is 99% on room air. Physical exam reveals a confused man who is moving all 4 extremities and is protecting his airway. During the exam, he develops a tonic-clonic seizure, which lasts 1 minute and then terminates on its own. The patient is given intravenous fluids, and basic laboratory studies are drawn and pending. A urine dipstick is positive for red blood cells. Which of the following is most likely to be seen on laboratory testing? | {
"A": "Hyperkalemia",
"B": "Hyperphosphatemia",
"C": "Hyperuricemia",
"D": "Hypocalcemia",
"E": "Hyponatremia"
} | Hypocalcemia | D |
A 3-week-old boy presents to the emergency department with vomiting. His parents report that he suddenly started vomiting this morning and has shown no interest in feeding since then. They describe the vomitus as green and without any traces of blood. Prior to today, the patient was feeding, voiding, and stooling well. He was noted to have surpassed his birth weight at his last office visit 1 week ago. His temperature is 97.6°F (36.4°C), blood pressure is 78/56 mmHg, pulse is 148/min, and respirations are 44/min. On physical exam, the patient is in mild distress. He has no dysmorphic features, and his mucous membranes are dry. His abdomen is soft and distended. Bowel sounds are hypoactive. An abdominal radiograph is performed as in Figure A. Which of the following is the most appropriate next step in the diagnosis of this condition? | {
"A": "Abdominal CT",
"B": "Abdominal ultrasound",
"C": "Contrast enema",
"D": "Rectal suction biopsy",
"E": "Upper gastrointestinal contrast series"
} | Upper gastrointestinal contrast series | E |
A 6-year-old boy is brought to the emergency department by his father for elbow pain. He was riding his bicycle when he fell onto his outstretched right hand. He immediately clutched his right elbow in pain and began crying. He refuses to move his elbow. He has no medical problems and takes no medications. His temperature is 98.4°F (36.9°C), blood pressure is 108/64 mmHg, pulse is 100/min, and respirations are 20/min. On exam, the boy is holding his right wrist with his left hand and cries upon palpation of a region that is 2 cm proximal to his elbow. The radial head is palpated just distal to the lateral epicondyle. He is unable to make a pincer with his right thumb and index finger. When asked to hold a pen between his right thumb and index fingers, he drops it. The radial pulse is diminished on the right. Which of the following is the most likely diagnosis? | {
"A": "Both bone forearm fracture",
"B": "Distal radius fracture",
"C": "Monteggia fracture-dislocation",
"D": "Olecranon fracture",
"E": "Supracondylar humerus fracture"
} | Supracondylar humerus fracture | E |
A 65-year-old man presents to the emergency department for evaluation of left arm and leg weakness. He was walking in the park about 45 minutes prior to arrival when the patient stumbled and fell. He had sudden weakness in his left leg and was unable to grasp a handrail with his left hand. He currently takes no medications. His temperature is 98.0°F (36.6°C), blood pressure is 128/89 mmHg, pulse is 130/min, and respirations are 18/min. On exam, he has 3/5 strength in the left upper and lower extremities and a left-sided facial droop. A non-contrast CT scan of the head is performed, which suggests parenchymal ischemia in the distribution of the right middle cerebral artery. An ECG is performed, as shown in Figure A. He is given intravenous alteplase with rapid improvement in his strength deficits and facial asymmetry. Which of the following is the most appropriate long-term therapy for secondary stroke prevention for this patient? | {
"A": "Aspirin",
"B": "Atorvastatin",
"C": "Cardiac pacemaker",
"D": "Rivaroxaban",
"E": "Warfarin"
} | Rivaroxaban | D |
A previously healthy 15-year-old boy presents to the emergency department in cardiac arrest. He was in class when he suddenly fainted and became unresponsive. His teacher began chest compressions and he has received epinephrine and defibrillation from paramedics while in transport. On arrival, the patient remains pulseless and is pronounced dead. An autopsy is performed and is notable for no clear abnormalities. The patient’s laboratory studies were unremarkable from a visit to the pediatrician 3 weeks ago. A previous ECG is seen in Figure A. Which of the following is the most likely underlying etiology of this patient’s death? | {
"A": "Complete heart block",
"B": "Short QT syndrome",
"C": "Torsades des pointes",
"D": "Ventricular fibrillation",
"E": "Ventricular tachycardia"
} | Short QT syndrome | B |
A 72-year-old man presents to his primary care physician with weakness. He has felt very weak every morning with his symptoms persisting throughout the day. He notes minor improvement when he rides his bike but otherwise has not noticed any change in his symptoms with rest or ibuprofen use. The patient has lost 12 pounds recently and has had a chronic cough. The patient lives alone and drinks 7 alcoholic beverages per day and smokes 1-2 packs of cigarettes per day for the past 40 years. His temperature is 99.5°F (37.5°C), blood pressure is 177/108 mmHg, pulse is 93/min, respirations are 17/min, and oxygen saturation is 92% on room air. A chest radiograph is ordered as seen in Figure A. Which of the following diagnostic tests would most likely elucidate the cause of this patient's weakness? | {
"A": "Blood laboratory test",
"B": "CT scan of the chest",
"C": "Electromyography",
"D": "Lung biopsy",
"E": "Muscle biopsy"
} | Electromyography | C |
A 28-year-old man is brought to the emergency department by helicopter after a high speed motorcycle crash. He was intubated and 2 large bore IVs were placed in the field with administration of 2 liters of lactated ringer's solution while en route. On arrival to the emergency department, his temperature is 98.6°F (37.0°C), pulse is 130/min, blood pressure is 80/50 mmHg, respirations are 22/min, and oxygen saturation is 97%. Examination reveals an ill-appearing intubated patient. Endotracheal tube placement is confirmed with end tidal CO2, and bilateral breath sounds are present. No external bleeding or wounds are noted on exam. Pulses are present in all extremities but are weak and rapid. Significant bruising is noted over the abdomen. The pelvis is stable. Infusion of packed red blood cells is initiated. Which of the following is the most appropriate next step in management? | {
"A": "Anterior-posterior and lateral radiographs of the abdomen and pelvis",
"B": "CT scan of the abdomen and pelvis with contrast",
"C": "Diagnostic peritoneal lavage",
"D": "FAST exam",
"E": "Norepinephrine infusion"
} | FAST exam | D |
A 55-year-old man presents to his primary care physician with fatigue, malaise, and a painful rash. The patient states that his symptoms have been worsening over the past week. He also has experienced abdominal pain and diarrhea. He has a medical history of obesity and smokes regularly. His temperature is 97.5°F (36.4°C), blood pressure is 142/82 mmHg, pulse is 85/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for an erythematous rash with papules and plaques on the patient's face, torso, and extremities. He states that the rash is painful. A fingerstick blood glucose is unable to accurately read his blood glucose and gives a reading of > 500 mg/dL. Which of the following is the most likely underlying pathophysiology of this patient’s condition? | {
"A": "Alpha cell tumor",
"B": "Beta cell destruction",
"C": "Beta cell tumor",
"D": "Hypercortisolism",
"E": "Insulin resistance"
} | Alpha cell tumor | A |
A 67-year-old man presents with a recurrent episode of syncope. He states that this has happened to him multiple times, particularly when he changes body position from sitting to standing, exerts himself, or turns his head quickly. He says that he notes numbness, vertigo, and sometimes even trouble with speaking immediately prior to fainting. The episodes usually last 1-5 minutes. When he wakes up, he is mildly confused but typically returns to baseline within a minute. The patient has a past medical history of diabetes, dyslipidemia, and hypertension. His temperature is 98.5°F (36.9°C), blood pressure is 153/89 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air. The patient's neurological exam is unremarkable. However, when he is asked to stand up and start walking, he experiences the same numbness and tingling and feels like he may faint. Which of the following is the most likely diagnosis? | {
"A": "Blood vessel narrowing",
"B": "Cardiac dysrhythmia",
"C": "Seizure",
"D": "Stroke",
"E": "Vagal event"
} | Blood vessel narrowing | A |
A 30-year-old man presents to the emergency department with diarrhea. He states he has had profuse, watery diarrhea for the past 24 hours. He notes that eating and drinking make him defecate more, thus he has been refraining from drinking. He is otherwise healthy and takes no medications. His temperature is 97.7°F (36.5°C), blood pressure is 84/64 mmHg, pulse is 130/min, respirations are 17/min, and oxygen saturation is 99% on room air. Physical exam reveals dry mucous membranes with an otherwise benign exam. The patient is given 1L of normal saline and drinks 1L of oral fluids. His blood pressure is subsequently 120/70 mmHg and pulse 95/min. Which of the following is the most appropriate next step in management? | {
"A": "Ciprofloxacin",
"B": "Rest and oral rehydration",
"C": "Stool culture",
"D": "Stool ova and parasite study",
"E": "Stool PCR"
} | Rest and oral rehydration | B |
A 23-year-old woman presents to the emergency department for evaluation of fever and chills over the last several days along with a progressive rash and diarrhea. She had nasal septoplasty performed 1 week prior and has had nasal packing in place since that time. Her rash has progressed and the skin on her hands is "peeling." She has no significant medical history and takes no medications. Her temperature is 102°F (38.9°C), blood pressure is 84/54 mmHg, pulse is 160/min, respirations are 22/min, and oxygen saturation is 99% on room air. Exam reveals an ill-appearing woman. A diffuse, macular, erythematous rash is noted with desquamation over the patient's hands as shown in Figure A. Bilateral conjunctivitis is noted. The patient's nasal packing is removed revealing copious, foul-smelling, purulent discharge. Which of the following pathogens is likely responsible for this patient's condition? | {
"A": "Borrelia burgdorferi",
"B": "Neisseria meningitides",
"C": "Rhinovirus",
"D": "Rickettsia rickettsii",
"E": "Staphylococcus aureus"
} | Staphylococcus aureus | E |
Figure A is the lateral radiograph of a 44-year-old male who sustained a fall on his outstretched hand while rollerblading. The patient reports pain localized to the posterior elbow and refuses to attempt elbow extension secondary to pain and swelling. Which of the following is the most likely diagnosis in this patient? | {
"A": "Exacerbation of elbow arthritis",
"B": "Triceps rupture",
"C": "Olecranon bursitis",
"D": "Lateral collateral ligament tear",
"E": "Anconeus avulsion fracture"
} | Triceps rupture | B |
A 46-year-old woman presents to her primary care doctor to request a referral to ophthalmology. Her vision has been steadily declining over the past 2 years and she thinks she needs a prescription for glasses. She further complains that her lips and feet feel numb. Her medical history is notable for medullary thyroid cancer status post total thyroidectomy. Her periods are regular. She enjoys a diverse diet and takes levothyroxine. Her blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 12/min. She is alert and oriented. Her pupils are equal, round, and reactive to light, but appear opacified. Extraocular movements are intact, albeit slow. Her visual acuity is decreased bilaterally. The remainder of her physical exam is unremarkable. Her basic metabolic panel is shown below: Na+: 139 mEq/L Cl-: 100 mEq/L K+: 4.9 mEq/L HCO3-: 25 mEq/L BUN: 10 mg/dL Glucose: 110 mg/dL Creatinine: 0.8 mg/dL Thyroid-stimulating hormone: 1.5 µU/mL Ca2+: 7.0 mEq/L Phosphorus: 6.5 mEq/L Albumin: 3.6 mg/dL The patient's ECG is shown in Figure A. What is the most likely cause of this presentation? | {
"A": "Hyperkalemia",
"B": "Iatrogenic hypoparathyroidism",
"C": "Iatrogenic hypothyroidism",
"D": "Multiple endocrine neoplasia",
"E": "Somatization"
} | Iatrogenic hypoparathyroidism | B |
A 35-year-old G0P0000 woman presents to her gynecologist with complaints of irregular menstruation. She has had only 2 periods in the last year. She feels flushed without provocation and is experiencing occasional dyspareunia with post-coital spotting. She has also had more frequent headaches than usual. The patient has a medical history of Hashimoto thyroiditis and takes levothyroxine daily. Her mother has type 1 diabetes mellitus. Her temperature is 98.5°F (36.9°C), pulse is 70/min, blood pressure is 118/76 mmHg, and respirations are 13/min. Cardiopulmonary and abdominal exams are unremarkable. The patient has Tanner 5 breasts and pubic hair. A pelvic exam reveals a normal cervix, an anteverted uterus without tenderness, and no adnexal masses. The following laboratory studies are performed: Serum: Thyroid stimulating hormone (TSH): 28 µIU/mL (9-30 µIU/mL) Cycle day 3 follicle stimulating hormone (FSH): 49 mIU/mL (4.7-21.5 mIU/mL) Cycle day 3 estradiol: 8 pg/mL (27-123 pg/mL) Prolactin: 14 ng/mL (4-23 ng/mL) Testosterone: 42 ng/dL (15-70 ng/dL) Which of the following is the most appropriate next step in management? | {
"A": "Brain MRI",
"B": "Combined oral contraceptive",
"C": "Estradiol patch with oral medroxyprogesterone",
"D": "Increase levothyroxine dose",
"E": "Vaginal estradiol gel"
} | Estradiol patch with oral medroxyprogesterone | C |
A 27-year-old man presents to his primary care physician for exposure to toxic materials. The patient states that when he left for work this morning he was certain that he had closed the door to his pantry. Upon returning home, he saw that the door to his pantry was wide open. The patient is certain that his neighbors have been tampering with his food and potentially poisoned him. He further states that he knows they have been trying to break into his house and steal his things. He has tried multiple times to get them evicted from the building to no avail. It is for this reason that he is certain that they are trying to get their revenge upon him. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. The physician performs a physical exam and tells the patient that he thinks there is nothing to be concerned about, but that he should call him or come into the office if he experiences any symptoms. The patient is outraged at this news and requests a competent doctor who is not colluding with his enemies. He storms out of the office angrily, stating that he deserves the best in medical care. Which of the following is the most likely disorder that this patient is suffering from? | {
"A": "Borderline personality disorder",
"B": "Intermittent explosive disorder",
"C": "Narcissistic personality disorder",
"D": "Paranoid personality disorder",
"E": "Schizoid personality disorder"
} | Paranoid personality disorder | D |
A 27-year-old woman presents to the emergency department with altered mental status. Her boyfriend found her at home next to a suicide note and brought her into the emergency department. According to her boyfriend, the patient has a medical history of bipolar disorder for which she takes lithium, as well as chronic lower back pain for which she sees a pain specialist. Her temperature is 100.5°F (38.1°C), blood pressure is 102/78 mmHg, pulse is 127/min, respirations are 19/min, and oxygen saturation is 99% on room air. An ECG is performed as seen in Figure A. Which of the following findings is also likely to be present at some point in this patient’s course? | {
"A": "Diaphoresis",
"B": "Jaundice",
"C": "Miosis",
"D": "Urinary retention",
"E": "Wheezing"
} | Urinary retention | D |
A 40-year-old south asian man presents to a primary care provider with a chronic cough that is worse at night. He has had the cough for several years but it has been getting worse over the last few months. He recently moved to the United States to work in construction. He has lost 10 pounds in the last 3 months along with darker stools which he believes is caused by a Western diet. He denies any difficulty swallowing or feeling of food getting stuck in his throat. He drinks alcohol 1-2 times per week and has never smoked. He denies any family history of cancer. His temperature is 98.6°F (37°C), blood pressure is 114/72 mmHg, pulse is 82/min, and respirations are 12/min. On physical exam, his lungs are clear to auscultation bilaterally without wheezing. His abdomen is soft and non-distended. He has no tenderness to palpation and bowel sounds are present. Which of the following is the most appropriate next step in management? | {
"A": "Barium swallow",
"B": "Colonoscopy",
"C": "Helicobacter pylori stool antigen test",
"D": "Trial of lansoprazole",
"E": "Upper endoscopy"
} | Upper endoscopy | E |
A 10-year-old girl is admitted to the medical floor for a respiratory infection. The patient lives in a foster home and has been admitted many times. Since birth, the patient has had repeated episodes of pain/pressure over her frontal sinuses and a chronic cough that produces mucus. She was recently treated with amoxicillin for an infection. The patient is in the 25th percentile for height and weight which has been constant since birth. Her guardians state that the patient has normal bowel movements and has been gaining weight appropriately. The patient has a history of tricuspid stenosis. She also recently had magnetic resonance imaging (MRI) of her chest which demonstrated dilation of her airways. Her temperature is 99.5°F (37.5°C), blood pressure is 90/58 mmHg, pulse is 120/min, respirations are 18/min, and oxygen saturation is 94% on room air. Physical exam is notable for bruises along the patient's shins which the guardians state are from playing soccer. The rest of the exam is deferred because the patient starts crying. Which of the following findings is associated with this patient's most likely underlying diagnosis? | {
"A": "Diastolic murmur best heard along the right lower sternal border",
"B": "Hypocalcemia",
"C": "Increased chloride in the patient's sweat",
"D": "Repeat sinus infections secondary to seasonal allergies",
"E": "Social withdrawal and avoidance of eye contact"
} | Diastolic murmur best heard along the right lower sternal border | A |
A 4-day-old boy presents to the pediatrician with his mother for his 1st well visit. The patient was born at 36 weeks gestation to a 26-year-old primigravid mother via cesarean section for cervical incompetence. The patient required no resuscitation at birth and both mother and child were discharged from the hospital at 2 days of life. The patient has been exclusively breastfed since birth, and his mother reports that he feeds for 20-30 minutes every 2 hours. The patient urinates 7 times per day and has begun passing 2-3 stools per day that his mother describes as “grainy” and the color of “mustard.” His birth weight was 3670 g (8 lb 1 oz), and his current weight is 3487 (7 lb 11 oz). His temperature is 97.1°F (36.2°C), blood pressure is 57/42 mmHg, pulse is 140/min, and respirations are 38/min. On physical exam, the patient’s anterior fontanelle is soft and flat, and his eyes are moderately icteric. His abdomen is soft and non-distended. The patient has the physical exam finding seen in Figure A. His diaper can be seen in Figure B. Laboratory studies reveal the following:
Total bilirubin: 13 mg/dL
Conjugated bilirubin: 0.6 mg/dL
Which of the following is the most appropriate next step in management? | {
"A": "Administer intravenous hydration",
"B": "Continue current breastfeeding regimen",
"C": "Order serum uric acid concentration",
"D": "Order spot uric acid to creatinine ratio",
"E": "Recommend increasing frequency of breastfeeding"
} | Continue current breastfeeding regimen | B |
A 32-year-old G1P0 presents to the antenatal testing unit at 32 weeks of gestation for a non-stress test (NST). Yesterday she had several episodes of diarrhea and vomited once after attending a company picnic 2 days ago. She took loperamide with symptomatic relief. She is worried that she is dehydrated but otherwise feels well and has recovered from her gastrointestinal illness. The patient was diagnosed with gestational diabetes after routine screening in the 2nd trimester and has been started on insulin after unsuccessful attempts at lifestyle management. She also has migraines and gastroesophageal reflux disorder. The patient has a 15-pack-year smoking history but quit smoking in her 1st month of pregnancy. She denies alcohol or drug use. Her temperature is 98.5°F (36.9°C), blood pressure is 122/82 mmHg, pulse is 84/min, and respirations are 14/min. A representative portion of the NST is shown in Figure A. Which of the following is the most likely explanation for this patient’s non-stress test (NST) results? | {
"A": "Fetal sleep cycle",
"B": "Maternal dehydration",
"C": "Maternal medication use",
"D": "Maternal smoking",
"E": "Normal results"
} | Fetal sleep cycle | A |
A 25-year-old man presents to his primary care physician with a chief complaint of "failing health." He states that he typically can converse with animals via telepathy but is having trouble right now due to the weather. He has begun taking an assortment of Peruvian herbs to little avail. Otherwise, he is not currently taking any medications. The patient lives alone and works in a health food store. He states that his symptoms have persisted for the past 8 months. When obtaining the patient's medical history, there are several times he attempts to telepathically connect with the animals in the vicinity. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, you note a healthy young man who is dressed in an all-burlap ensemble. Which of the following is the most likely diagnosis? | {
"A": "Brief psychotic disorder",
"B": "Schizoid personality disorder",
"C": "Schizophrenia",
"D": "Schizophreniform disorder",
"E": "Schizotypal personality disorder"
} | Schizotypal personality disorder | E |
A 55-year-old man presents to the emergency department with chest pain and shortness of breath. He has a medical history of hypertension, diabetes, and obesity. His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air. An ECG is performed and notable for ST elevation in leads II, III, and aVF. The patient is treated appropriately and transferred to the medical floor. On the 2nd day of his hospitalization, the patient has abdominal pain. His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL. A physical exam is notable for the finding in Figure A. He is requesting pain medication for his abdominal pain. Which of the following is the most likely underlying diagnosis? | {
"A": "Cholesterol embolism",
"B": "Heart failure and reinfarction",
"C": "Medication side effect",
"D": "Pancreatitis",
"E": "Renal failure"
} | Cholesterol embolism | A |
A 25-year-old man is brought to the emergency department by paramedics for altered mental status. He was found lying down at a bus stop unresponsive. On arrival, the patient has slurred speech and is somnolent. Further is unable to be elicited. His temperature is 98.0°F (36.7°C), blood pressure is 130/80 mmHg, pulse is 80/min, and respirations are 12/min with a saturation of 97% on room air. Physical exam reveals a sleeping man with miotic pupils. The patient is easily arousable to voice and sternal rub but falls asleep rapidly. He has decreased bowel sounds. He is able to state his name and knows that he is at the hospital and has an otherwise normal neurologic exam. Which of the following is the most appropriate management? | {
"A": "Atropine",
"B": "Disulfiram",
"C": "Flumazenil",
"D": "Naloxone",
"E": "Observation"
} | Observation | E |
A 32-year-old man presents to the emergency department with pain upon defecation. His symptoms started a few weeks ago but have been worsening. Sometimes he notes blood on the toilet paper. He has to strain to have bowel movements and has trouble defecating secondary to pain. He is generally healthy and does not smoke. The patient is a software engineer and enjoys hiking, going to nightclubs, and dancing. His temperature is 98.1°F (36.7°C), blood pressure is 112/83 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals a small, superficial fissure that is lateral to the anus and lateral to the midline. Which of the following is the most appropriate management for this patient? | {
"A": "CT scan of the abdomen and pelvis",
"B": "Incision, drainage, ciprofloxacin, and metronidazole",
"C": "Surgical excision",
"D": "Testing for HIV, fecal occult blood, and sexually transmitted diseases",
"E": "Topical lidocaine, sitz baths, and fiber supplements"
} | Testing for HIV, fecal occult blood, and sexually transmitted diseases | D |
A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL. He was appropriately treated and discharged home. Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible. His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min. A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy. Which of the following is the most appropriate next step in management? | {
"A": "Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies",
"B": "Determine drug sensitivities against the patient’s pulmonary infection",
"C": "Discontinue antimicrobial treatment",
"D": "Obtain a D-dimer level",
"E": "Start high-dose glucocorticoid treatment and discontinue antiretroviral therapy"
} | Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies | A |
A 55-year-old man presents to the emergency department with chest pain and shortness of breath. He has a medical history of hypertension, diabetes, and obesity. His temperature is 98.6°F (37.0°C), blood pressure is 177/118 mmHg, pulse is 127/min, respirations are 11/min, and oxygen saturation is 98% on room air. An ECG is performed and notable for ST elevation in leads II, III, and aVF. The patient is treated appropriately and transferred to the medical floor. On the 2nd day of his hospitalization, the patient has abdominal pain. His serum lipase is 272 U/L and his creatinine is 1.6 mg/dL. A physical exam is notable for the finding in Figure A. He is requesting pain medication for his abdominal pain. Which of the following is the most likely underlying diagnosis? | {
"A": "Cholesterol embolism",
"B": "Heart failure and reinfarction",
"C": "Medication side effect",
"D": "Pancreatitis",
"E": "Renal failure"
} | Cholesterol embolism | A |
A 32-year-old man presents to his primary care provider for a headache. He reports that he has headaches at night several times a week. He first developed these headaches over 1 year ago, but they started up again 3 weeks ago. The episodes start suddenly and feel like a stabbing, electrical pain over his left eye. He also reports tearing of the left eye during these episodes. The headaches self-resolve over the course of 2-3 hours, but the patient complains that he is avoiding going to sleep for fear of waking up in pain. His medical history includes type 1 diabetes mellitus and an episode of herpes zoster on his right flank 1 year ago. His only home medication is insulin. His temperature is 98.6°F (37°C), blood pressure is 112/69 mmHg, pulse is 61/min, and respirations are 14/min. On physical exam, his extraocular muscles are intact and his eyes are not injected. A CT of the head and sinuses shows no acute abnormalities. Which of the following is most likely to prevent future episodes of headache in this patient? | {
"A": "Carbamazepine",
"B": "High-flow oxygen",
"C": "Sumatriptan",
"D": "Topiramate",
"E": "Verapamil"
} | Verapamil | E |
A 62-year-old man presents to the emergency department with skin lesions. He felt itchy recently, then noticed skin lesions that broke out prompting him to come to the emergency department. He recently went camping and hiking in the woods. The patient drinks 1-2 beers per day and smokes 1 pack of cigarettes per day. He is currently sexually active with multiple partners and does not use condoms. The patient was discharged 1 week ago for pneumonia which was treated with azithromycin; however, he feels that his symptoms may be returning. His temperature is 99.5°F (37.5°C), blood pressure is 157/78 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals the findings in Figure A on the patient's arm. The skin lesions are thick and do not break when pressure is applied. Which of the following most appropriately describes the most likely diagnosis? | {
"A": "IgG in a fish-net pattern",
"B": "Linear IgG along the basement membrane",
"C": "Multi-nucleated giant cells",
"D": "Panniculitis",
"E": "Type IV hypersensitivity reaction"
} | Linear IgG along the basement membrane | B |
A 45-year-old man presents to his primary care physician with a rash. He first noticed the rash 2 weeks prior and he endorses intermittent itchiness from the rash. His medical history is significant for chronic hepatitis C infection, hypertension, type 2 diabetes mellitus, and heart failure. The patient works as a butcher at a local meat processing shop and is sexually active with several partners. He does not use barrier protection. His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 155/95 mmHg, and respirations are 12/min. On physical exam, his skin has the finding shown in Figure A. Fine, lace-like white lines are also noted on the patient’s buccal mucosa. Which of the following is the most likely diagnosis? | {
"A": "Atopic dermatitis",
"B": "Lichen planus",
"C": "Prurigo nodularis",
"D": "Psoriasis",
"E": "Scabies"
} | Lichen planus | B |
A 27-year-old woman presents to her primary care physician with new hair growth on her face and lower abdomen over the last month. She has started to develop pimples on her face and back over the last several months. Her last menstrual period was over 3 months ago and her periods have been irregular over the last year. She has been gaining weight recently. The patient has a medical history of obesity and prediabetes with a hemoglobin A1c of 6.0% last year. Her temperature is 98.5°F (36.9°C), pulse is 80/min, blood pressure is 139/88 mmHg, and respirations are 13/min. Cardiopulmonary exam is unremarkable, and the patient’s abdomen appears slightly distended but exhibits no tenderness to palpation. The patient’s face has coarse stubble along the jawline and on the upper lip, and there is similar hair along the midline of her lower abdomen. A pelvic exam reveals mild clitoromegaly, a normal anteverted uterus, and a large left adnexal mass that is mildly tender. Her laboratory test results are shown below:
Hemoglobin: 13.9 g/dL
Leukocyte count: 8,000 cells/mm^3
Platelet count: 142,000/mm^3
DHEAS: 73 ug/dL (Normal: 145-395 ug/dL)
Testosterone: 256 ng/dL
17-hydroxyprogesterone: 214 ng/dL (Normal: < 200 ng/dL)
Ultrasound findings are shown in Figure A. Which of the following is the most likely diagnosis in this patient? | {
"A": "Adrenal tumor",
"B": "Congenital adrenal hyperplasia",
"C": "Ovarian hyperthecosis",
"D": "Ovarian tumor",
"E": "Polycystic ovary syndrome"
} | Ovarian tumor | D |
A study is performed that looks at individuals who suffer from opioid use disorder and the effect the disorder has on their daily life and functionality. Individuals are surveyed using a validated method and followed up in 6-month intervals for 5 years. At the end of the study period, 40% of individuals have replied to the survey throughout the entire period. Analyzing only those subjects who responded throughout the entire period, it is determined that opioid use disorder only minimally impairs individuals in their daily functioning. Which of the following most likely occurred in this study? | {
"A": "Attrition bias",
"B": "Confounding variable",
"C": "Late-look bias",
"D": "Recall bias",
"E": "Volunteer bias"
} | Attrition bias | A |
A 62-year-old woman is brought to a physician by her husband for fluctuating changes in behavior and hallucinations over the past 2 years. On occasion, she becomes difficult to understand and her speech becomes disorganized. She also frequently sees "small people" and animals on the dining room table, which is disturbing to her. Her medical problems include hypertension and chronic obstructive pulmonary disease for which she takes amlodipine, albuterol, ipratropium, and a fluticasone inhaler. She was formerly an executive at a software company but had to retire due to frequent memory lapses. Her temperature is 98.6°F (37°C), blood pressure is 120/80 mmHg, pulse is 80/min, and respirations are 12/min. Physical exam is notable for slowed movements and difficulty with balance at rest, which were not present at her wellness visit 1 year ago. Which of the following pathological findings (Figures A-E) would most likely be seen if a brain biopsy were performed? | {
"A": "Figure A",
"B": "Figure B",
"C": "Figure C",
"D": "Figure D",
"E": "Figure E"
} | Figure C | C |
A 6-month-old boy is brought to the physician by his mother for abnormal movements. Several times a day, he experiences paroxysmal episodes of crying, bending at the waist, and jerking of the arms and legs. These episodes last 1-2 seconds, but occur in clusters every 20-30 seconds for several minutes. His mother's pregnancy, labor, delivery, and his neonatal course have been unremarkable. He is rolling over less frequently than before, has worse head control, and no longer smiles socially. His temperature is 98.6°F (37°C), blood pressure is 92/46 mmHg, pulse is 115/min, and respirations are 34/min. On examination, no dysmorphic features are noted. A 24-hour electroencephalography (EEG) is performed, during which the patient has one of these spells. A chaotic pattern of slowing and multifocal epileptiform charges is seen. Which of the following is the pathophysiology of this patient's condition? | {
"A": "Abnormalities in T-type calcium channels",
"B": "Anti-N-methyl-D-aspartate (NMDA) receptor antibodies",
"C": "Decreased gamma aminobutyric acid (GABA) levels",
"D": "Excess of corticotropin releasing hormone",
"E": "Vitamin B6 deficiency"
} | Excess of corticotropin releasing hormone | D |
A 23-year-old woman is admitted to the inpatient psychiatry unit after her boyfriend reported she was “acting funny and refusing to talk.” The patient’s boyfriend states that he came home from work and found the patient sitting up in bed staring at the wall. When he said her name or waved his hand in front of her, she did not respond. When he tried to move her, she would remain in whatever position she was placed. Her temperature is 99°F (37.2°C), blood pressure is 122/79 mmHg, pulse is 68/min, and respirations are 12/min with an oxygen saturation of 98% on room air. The patient is lying on the bed with her left arm raised and pointing at the ceiling. She resists any attempt to change her position. The patient remains mute and ignores any external stimuli. The patient’s medical history is significant for depression. She was recently switched from phenelzine to fluoxetine. Which of the following is the most appropriate initial therapy? | {
"A": "Benztropine",
"B": "Cyproheptadine",
"C": "Electroconvulsive therapy",
"D": "Haloperidol",
"E": "Lorazepam"
} | Lorazepam | E |
A 30-year-old man presents to the emergency room with a laceration over the 4th metacarpophalangeal (MCP) joint of his right hand. He reports that he is a mailman, and his closed fist was bitten by a dog while he was delivering mail yesterday. He reports pain but denies fevers, chills, drainage, or any other symptoms. The dog is up to date on vaccinations. His last tetanus vaccine was 3 years ago. He has no medical history and takes no medications. His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 125/75 mmHg, and respirations are 16/min. Examination of the patient's right hand is shown in Figure A. Which of the following is the most appropriate next step in management? | {
"A": "Amoxicillin-clavulanate",
"B": "Cephalexin",
"C": "Clindamycin",
"D": "Clindamycin plus doxycycline",
"E": "Wound closure and amoxicillin-clavulanate"
} | Amoxicillin-clavulanate | A |
A 59-year-old woman presents to her primary care physician for trouble sleeping. 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. 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 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 most appropriate initial step in management? | {
"A": "Alprazolam",
"B": "Ferrous sulfate",
"C": "Iron studies",
"D": "Pramipexole",
"E": "Supportive therapy and an exercise routine"
} | Iron studies | C |
A 35-year-old man presents to the emergency department with altered mental status. He was found by his roommate to be disoriented this morning. He had complained of a right-sided headache for the past 5 days. He has a history of human immunodeficiency virus (HIV) infection being treated with bictegravir, emtricitabine, and tenofovir. His last CD4 cell count was 500/mm^3. He does not smoke tobacco and drinks alcohol socially. His temperature is 104.2°F (40.1°C), blood pressure is 110/70 mmHg, pulse is 110/min, and respirations are 22/min. Examination reveals 3/5 strength to right shoulder abduction and elbow flexion/extension and 4/5 strength to right hip flexion/extension. The remainder of the strength exam on the right and left sides is normal. Neck flexion does not elicit pain, and there are no tongue lacerations. During the exam, the patient’s eyes are seen to roll backward with repeated flexion/extension of his extremities and loss of urine. This stops after 1 minute. Which of the following is the most likely diagnosis? | {
"A": "Bacterial meningitis",
"B": "Brain abscess",
"C": "Cytomegalovirus encephalitis",
"D": "Epilepsy",
"E": "Fungal meningitis"
} | Brain abscess | B |
A 24-year-old man with epilepsy refractory to valproic acid, phenytoin, and levetiracetam undergoes magnetic resonance imaging of his brain while monitored by anesthetic care. He wakes up screaming in pain due to an electrocardiogram lead having caused a significant thermal burn circumferentially around his left leg. He is admitted to the medical intensive care unit for continuous electroencephalogram monitoring while on a midazolam infusion for seizure suppression and supportive care for his burn. Overnight, the nurse continued to increase the patient's midazolam infusion rate, but she also noticed that his left toes were cold to the touch with significant edema. His temperature is now 100°F (37.8°C), blood pressure is 110/75 mmHg, pulse is 80/min, respirations are 10/min and oxygen saturation is 95% on 2 liters nasal cannula. No dorsalis pedis or posterior tibial pulses are detected on the left lower extremity. A delta pressure of 25 mmHg is obtained in the left leg. What is the most appropriate next step in management? | {
"A": "Amputation",
"B": "Escharotomy",
"C": "Fasciotomy",
"D": "Intravenous fluid infusion based on Parkland formula",
"E": "Transfer to burn center"
} | Escharotomy | B |
A 27-year-old woman presents for her first prenatal visit at an estimated gestational age of 16 weeks and 4 days by last menstrual period. She is presenting late to prenatal care due to significant anxiety about her pregnancy, as she and her husband had struggled with infertility for several years prior to conceiving. She has had nausea and vomiting for about 2 months, tender and swollen breasts, and cravings for foods she typically does not eat. She took a pregnancy test about 10 weeks ago and was too nervous to read the result immediately. After 24 hours, she saw that it was positive. The patient has a past medical history of bulimia nervosa but has not been symptomatic in 2 years. She also had an appendectomy at age 15 for appendicitis. She is a Ph.D. student and her husband is a physician. Her temperature is 98.5°F (36.9°C), pulse is 75/min, blood pressure is 122/76 mmHg, and respirations are 13/min. The patient’s affect is normal and she is pleasant and excited about her pregnancy. A physical exam is notable for abdominal distension but is otherwise unremarkable. Ultrasound is shown in Figure A, and urine human chorionic gonadotropin is negative in the office. Which of the following is the most likely diagnosis? | {
"A": "Couvade syndrome",
"B": "Delusion of pregnancy",
"C": "Feigned pregnancy",
"D": "Pseudocyesis",
"E": "Recent miscarriage"
} | Pseudocyesis | D |
A 42-year-old man presents to the urgent care clinic with low back pain. He was working on a home improvement project the day prior to presentation when the pain started. He describes the pain as "achy and sore." It is not positional and does not radiate. He denies fevers, chills, paresthesias, and bowel or bladder incontinence. He has a history of a distal radius fracture 2 years ago from falling off a ladder. He drinks 3 alcoholic beverages weekly and denies illicit drug use. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min. His body mass index (BMI) is 22.4 kg/m^2. There is tenderness to palpation of his paravertebral lumbar region bilaterally. Perineal and dermatomal sensation is symmetric and intact. Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion. Patellar and Achilles reflexes are 2+ bilaterally. Raising either leg while the patient is in the supine position does not elicit any pain. Which of the following is the most likely diagnosis? | {
"A": "Disc herniation",
"B": "Lumbar stenosis",
"C": "Lumbar strain",
"D": "Osteoarthritis",
"E": "Vertebral compression fracture"
} | Lumbar strain | C |
A 57-year-old man presents to the emergency department with several days of malaise, weakness, and night sweats. Today, he experienced a headache with blurry vision, thus prompting his presentation. The patient has a history of diabetes and is followed closely by an endocrinologist. Otherwise, he has lost 10 pounds over the past month. His temperature is 100°F (37.8°C), blood pressure is 122/90 mmHg, pulse is 84/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is notable for a thin man but is otherwise unremarkable. His visual acuity is 20/100 in both eyes, though he says that he normally has 20/20 vision. His gait is mildly ataxic as well, but his neurological exam is otherwise nonfocal. Laboratory studies are ordered as seen below.
Hemoglobin: 10 g/dL
Hematocrit: 31%
Leukocyte count: 57,500/mm^3 with 35% blasts
Platelet count: 109,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.1 Eq/L
HCO3-: 22 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Calcium: 10.0 mEq/L
Which of the following is the most likely diagnosis? | {
"A": "Acute lymphoblastic leukemia",
"B": "Acute myelogenous leukemia",
"C": "Chronic lymphocytic leukemia",
"D": "Chronic myelogenous leukemia",
"E": "Multiple myeloma"
} | Chronic myelogenous leukemia | D |
A 35-year-old man presents to the emergency department for evaluation of chest pain. The pain starts in his chest and moves into his back, arms, and abdomen. He describes the pain as tearing. He has no known medical history and takes no medications. His temperature is 37.0°C (98.6°F), pulse is 130/min, blood pressure is 210/145 mmHg, respirations are 22/min, and pulse oximetry is 98% on room air. Exam reveals a diaphoretic, anxious-appearing man. Pulses are diminished over the left wrist when compared to the right. A chest radiograph is obtained as shown in Figure A. Which of the following is the most appropriate next step in management? | {
"A": "Aspirin",
"B": "CT angiography of the chest, abdomen, and pelvis",
"C": "Echocardiography",
"D": "Lorazepam",
"E": "Serum troponin testing"
} | CT angiography of the chest, abdomen, and pelvis | B |
A 36-year-old man presents to the office for follow up after initiating antidepressant therapy. Two months ago, he was started on citalopram after several weeks of depressed mood, loss of interest in activities, depressed appetite, and inability to sleep. Today, he reports minimal improvement in his symptoms. He had some nausea after starting the medication, but this has resolved. He denies thoughts of suicide or self-harm. His temperature is 98.6°F (37.0°C), pulse is 80/min, blood pressure is 120/80 mmHg, respirations are 22/min, and oxygen saturation is 97% on room air. Exam reveals a depressed, tired appearing man. Which of the following is the most appropriate next step in management? | {
"A": "Add mirtazapine",
"B": "Electroconvulsive therapy",
"C": "Switch to amitriptyline",
"D": "Switch to paroxetine",
"E": "Switch to phenelzine"
} | Add mirtazapine | A |
A 65-year-old man presents to his primary care physician for stiffness in his arm. He has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a medical history of type 2 diabetes mellitus, obesity, and hypertension. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient leads a sedentary life in which he tends to stay home and watch television. He does not engage in any physical or strenuous activity. His temperature is 98.6°F (37°C), blood pressure is 138/85 mmHg, pulse is 75/min, and respirations are 12/min. On physical exam, the patient has decreased passive and active range of motion of his shoulder. The strength of the patient's upper extremity is 4/5 limited by pain. Which of the following is the most likely diagnosis? | {
"A": "Adhesive capsulitis",
"B": "Biceps tendinopathy",
"C": "Glenohumeral osteoarthritis",
"D": "Rotator cuff impingement",
"E": "Subacromial bursitis"
} | Adhesive capsulitis | A |
A 27-year-old man presents to the emergency department after a bar fight. He was punched in the eye and is having pain and blurry vision. The patient is otherwise healthy and does not take any medications. His temperature is 98.1°F (36.7°C), blood pressure is 132/84 mmHg, pulse is 103/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for conjunctival injection of the patient’s left eye as shown in Figure A. Visual acuity reveals 20/20 vision in his right eye and 20/40 vision in his left. His left pupil is sluggish to constrict when compared to the right. A fluorescein stain is unremarkable and tonometry reveals a pressure of 45 mmHg in the left eye. Which of the following is the most appropriate next step in management? | {
"A": "CT scan of the head and facial bones",
"B": "Cyclopentolate",
"C": "Lateral canthotomy",
"D": "Orbital ultrasound",
"E": "Topical timolol and pilocarpine"
} | Lateral canthotomy | C |
A 23-year-old woman presents to the emergency department with severe abdominal pain. The pain has been dull and progressive, but became suddenly worse while she was exercising. Her medical history is notable for depression, anxiety, and gonococcal urethritis that was appropriately treated. She is sexually active and does not use condoms. She admits to drinking at least 5 standard alcoholic drinks a day. The patient also recently lost a large amount of weight for a fitness show she planned on entering. The patient's current medications include oral contraceptive pills, fluoxetine, alprazolam, ibuprofen, acetaminophen, and folate. Her temperature is 99.5°F (37.5°C), blood pressure is 80/40 mmHg, pulse is 110/minute, and respirations are 15/minute with an oxygen saturation of 96% on room air. On physical exam, you note an athletic young woman with burly shoulders, a thick neck, and acne on her forehead and back. On abdominal exam you note diffuse tenderness with 10/10 pain upon palpation of the right upper quadrant. Intravenous fluids are started and labs are sent. A urinary ß-hCG has been ordered. Which of the following is the most likely the diagnosis? | {
"A": "Ectopic implantation of a blastocyst",
"B": "Inflammation of the pancreas",
"C": "Obstruction of blood flow through the hepatic vein",
"D": "Obstruction of the common bile duct by radio-opaque stones",
"E": "Vascular ectasia within the liver"
} | Vascular ectasia within the liver | E |
A 56-year-old man presents from prison with 1 month of subjective fevers, chills, cough, and night sweats. He noticed a gradual weight loss over the past year despite no changes to his diet or physical activity. He has never smoked cigarettes but does have a history of opiate use prior to incarceration. He does not take any medications. His temperature is 100.8°F (38.2°C), blood pressure is 142/88 mmHg, pulse is 78/min, and respirations are 12/min. Physical exam reveals a thin, ill-appearing man. Pulmonary auscultation reveals faint, inspiratory crackles in the right upper lobe. His chest radiograph is shown in Figure A. Which of the following is the most appropriate next step in management? | {
"A": "Ampicillin-sulbactam",
"B": "Biopsy",
"C": "Itraconazole",
"D": "Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy",
"E": "Vancomycin"
} | Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy | D |
A resident physician places a patient’s home medications in for their admission orders during an overnight admission. They order the patient’s home medications including clobazam; however, they accidentally order clonazepam. Subsequently, the patient is over-sedated and has to be transferred to the ICU for airway monitoring. Which of the following is the most appropriate method for preventing future similar occurrences? | {
"A": "Add an alert in the electronic medical system for medications that sound similar",
"B": "Enter medications only on morning rounds with multiple providers",
"C": "Have nursing perform the medication reconciliation",
"D": "Reprimand and educate the resident to check medications more carefully",
"E": "Verify the patient’s home medications with the patient"
} | Add an alert in the electronic medical system for medications that sound similar | A |
A 33-year-old man presents to the emergency department after slamming his finger in the car door 5 hours ago. He initially experienced pain which is currently well controlled with acetaminophen. The patient is otherwise healthy and does not take any medications. His temperature is 98.5°F (36.9°C), blood pressure is 123/79 mmHg, pulse is 90/min, respirations are 11/min, and oxygen saturation is 97% on room air. Physical exam is notable for the finding in Figure A. A radiograph of the affected digits shows a smooth cortex without disruption of the bone. Which of the following is the most appropriate management for this patient? | {
"A": "Excision and histological examination",
"B": "Fingernail removal",
"C": "Observation",
"D": "Operative repair",
"E": "Trephination"
} | Trephination | E |
A 27-year-old woman presents to her primary care physician for an abnormal vaginal discharge. The patient has engaged in unprotected intercourse with 12 different partners. She has a medical history of asthma, IV drug abuse, and depression. She has 1 to 2 alcoholic drinks per day. She feels ashamed of her behavior and is requesting treatment for her condition and advice for safe sex. The patient is given antibiotics and is advised on safe sex practices. The patient presents to the emergency department 3 days later with a complaint of a rash. She states that every time she has sex a rash has emerged on her skin. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 91/min, respirations are 14/min, and oxygen saturation is 98% on room air. A physical exam is notable for the finding in Figure A. Which of the following is the most likely cause of this patient's symptoms? | {
"A": "Antigen exposure",
"B": "Drug reaction",
"C": "Infection",
"D": "IV drug use",
"E": "Photosensitivity"
} | Antigen exposure | A |
A 46-year-old farmer presents to the office for a follow-up visit. He was seen 4 days ago for a new lesion on his arm that had been present for 1 week prior to that visit. A photograph of the lesion is shown in Figure A. At that time, he was prescribed treatment for the lesion and instructed to follow up as necessary. Today, he reports that he became sunburned this morning within an hour of beginning his workday, despite wearing appropriate sunscreen. He has a medical history significant for type 2 diabetes mellitus that is controlled with metformin. He has no known medical allergies. He smokes 1 pack of cigarettes per day and denies alcohol or illicit drug use. His temperature is 98.6°F (37.0°C), blood pressure is 125/70 mmHg, pulse is 65/min, and respirations are 12/min. On exam, there is a blistering erythematous rash on the arms and shoulders. The previous skin lesion appears unchanged. Which of the following is the most likely explanation for the patient's new rash? | {
"A": "Adverse effect of ciprofloxicin",
"B": "Adverse effect of doxycycline",
"C": "Allergic reaction to prescribed therapy",
"D": "Progression of disease and alternative therapy is indicated",
"E": "Progression of disease and surgical debridement is necessary"
} | Adverse effect of doxycycline | B |
A 16-year-old boy presents to an ophthalmologist with blurry vision. Over the past several months, he has had increasing difficulty seeing the board from the back of the classroom at school. The patient is otherwise doing well in school and enjoys playing basketball. His medical history is otherwise significant for scoliosis which is managed by an orthopedic surgeon. His family history is significant for a mother with type 2 diabetes mellitus and a father who underwent aortic valve replacement last year. His temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. On physical exam, the patient is tall for his age and has long arms. He has 20 degrees of thoracic scoliosis, which is stable from previous exams. On slit-lamp examination, the patient is found to have bilateral upward lens subluxation and is prescribed corrective lenses. Which of the following is the most likely cause of this patient’s symptoms? | {
"A": "Defective metabolism of methionine",
"B": "Extra copy of sex chromosome",
"C": "Mutation of chromosome 15",
"D": "Mutation of COL5A1 or COL5A2",
"E": "Mutation of RET proto-oncogene"
} | Mutation of chromosome 15 | C |
A 62-year-old man presents to the emergency department with increased fatigue and changes in his vision. For the past month, he has felt abnormally tired and today noticed his vision is blurry. The patient also endorses increased sweating at night and new-onset headaches. He currently feels dizzy. The patient has a medical history of diabetes and hypertension. His current medications include insulin, metformin, and lisinopril. His temperature is 99.5°F (37.5°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. A cardiopulmonary exam is within normal limits. HEENT exam reveals non-tender posterior and anterior chain lymphadenopathy. Abdominal exam reveals splenomegaly and hepatomegaly. There are large, non-tender palpable lymph nodes in the patient's inguinal region. A neurological exam is notable for decreased sensation in the patient's hands and feet. He also complains of numbness and tingling pain in his extremities that has been persistent during this time. The dermatologic exam is notable for multiple bruises on his upper and lower extremities. Which of the following is most likely to be abnormal in this patient? | {
"A": "Calcium",
"B": "IgA and IgG",
"C": "IgM",
"D": "Natural killer cells",
"E": "T-cells"
} | IgM | C |
A 26-year-old medical student presents to occupational health after sustaining a needlestick injury. She was drawing blood from an HIV-positive patient when she stuck herself percutaneously while capping the needle. She immediately washed the puncture wound with saline. The medical student has had a negative HIV serology from the beginning of medical school 2 years ago. She is monogamous with one male partner and denies any intravenous drug use. The source patient was recently diagnosed with HIV and has a CD4 count of 550 cells/µL. His most recent viral load is 1,800,000 copies/mL, and he was started on HAART 3 days ago. Which of the following is the most appropriate next step in management? | {
"A": "Immediately initiate triple antiretroviral therapy",
"B": "Perform genotype testing on source patient and initiate antiretroviral therapy tailored to results",
"C": "Repeat HIV serology and initiate triple antiretroviral therapy if negative",
"D": "Repeat HIV serology and initiate triple antiretroviral therapy if positive",
"E": "Repeat HIV serology and initiate triple antiretroviral therapy immediately"
} | Repeat HIV serology and initiate triple antiretroviral therapy immediately | E |
A 51-year-old man presents to the emergency department complaining of fever and a cough with yellow-green sputum for the past 3 days. He denies any hemoptysis, facial pain, rhinorrhea, or night sweats. The patient reported similar symptoms 2 months ago. Chest radiograph performed at the time was notable for a right middle lobe consolidation. He was diagnosed with lobar pneumonia and completed a 7-day course of antibiotics with complete resolution of his symptoms. He has no other significant medical history and does not take any medications. He has smoked 1 pack of cigarettes a day for 35 years and drinks 3 beers per week. He is sexually active with his wife. His temperature is 101.7°F (38.7°C), blood pressure is 127/85, pulse is 102/min, and respirations are 22/min. Physical exam is notable for decreased breath sounds on the right side without wheezing and increased dullness to percussion on the right side. A chest radiograph is ordered and reveals a consolidation in the right middle lobe. Which of the following is the most appropriate next step in management? | {
"A": "Barium swallow",
"B": "CT of the chest without contrast",
"C": "Human immunodeficiency virus (HIV) antibody assay",
"D": "Interferon-gamma release assay",
"E": "Serum immunoglobulin levels"
} | CT of the chest without contrast | B |
A 15-year-old boy is brought to his pediatrician for a follow-up visit. His parents report that he is doing well in school and has many friends. Their only concern is that he has a “difficult stomach.” Every few months, he complains of intermittent abdominal pain that takes several days to pass. He occasionally misses school due to the pain. There is blood in his stool during these episodes. These symptoms have persisted for many years. The parents have so far managed the condition using herbal teas and essential oils but have not sought formal medical care. His temperature is 98.2°F (36.8°C), blood pressure is 106/61 mmHg, pulse is 88/min, and respirations are 12/min. He has lost 10 pounds since his annual visit the year before and is the same height. On physical exam, the patient is thin with conjunctival pallor. His sclerae are anicteric and his abdomen is soft and non-tender without hepatosplenomegaly. He also has the findings seen in Figure A. He undergoes an abdominal CT that shows disease affecting the terminal ileum. Which of the following is most likely to be present in this patient? | {
"A": "Decreased mean corpuscular volume",
"B": "Decreased serum homocysteine level",
"C": "Increased serum methylmalonic acid level",
"D": "Microcytes",
"E": "Prolonged partial thromboplastin time"
} | Increased serum methylmalonic acid level | C |
A 55-year-old woman presents to the emergency department for evaluation of headache. She had a headache that was present for a few hours before subsiding 2 days ago, and then today she developed a headache that was sudden in onset and at maximal intensity within minutes. She has never had a headache like this in the past. Her temperature is 99.0°F (37.2°C), blood pressure is 157/99 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 99% on room air. On exam, she has pain with passive and active movement of the neck. No focal neurologic deficits are appreciated. A non-contrast head CT is obtained as shown in Figure A. Which of the following is the most likely underlying etiology of this patient's headache? | {
"A": "CNS vascular endothelial dysfunction",
"B": "Dehydration and stress",
"C": "Hypersensitivity of the trigeminal nerve",
"D": "Muscular pain and strain",
"E": "Rupture of a berry aneurysm"
} | Rupture of a berry aneurysm | E |
A 55-year-old man presents with a 2-day history of mono-articular joint pain. He is otherwise healthy and denies fever, chills, or recent trauma. His medical history is notable for a kidney stone 6 months ago. He underwent a dental procedure to extract an infected wisdom tooth 3 weeks ago. The patient does not take any medications. He is a non-smoker and does not drink alcohol or use recreational drugs. His family history is significant for osteoarthritis in his father who is 78. His temperature is 98.6°F (37°C), blood pressure is 133/84 mmHg, pulse is 84/min, and respirations are 15/min. His body mass index is 27 kg/m^2. Physical examination shows a swollen and tender joint with overlying erythema. Diagnostic arthrocentesis is performed and shows a leukocyte count of 30,000/mm^3 with 85% neutrophils. Polarized microscopy of the synovial fluid is shown in Figure A. Which of the following would most likely be found on this patient’s radiograph? | {
"A": "Boutonniere deformity",
"B": "Chondrocalcinosis",
"C": "Heberden nodes",
"D": "Juxta-articular osteoporosis",
"E": "Tophi"
} | Chondrocalcinosis | B |
A 1-year-old girl is brought to a neurologist due to increasing seizure frequency over the past 2 months. She recently underwent a neurology evaluation which revealed hypsarrhythmia on electroencephalography (EEG) with a mix of slow waves, multifocal spikes, and asynchrony. Her parents have noticed the patient occasionally stiffens and spreads her arms at home. She was born at 38-weeks gestational age without complications. She has no other medical problems. Her medications consist of lamotrigine and valproic acid. Her temperature is 98.3°F (36.8°C), blood pressure is 90/75 mmHg, pulse is 94/min, and respirations are 22/min. Physical exam reveals innumerable hypopigmented macules on the skin and an irregularly shaped, thickened, and elevated plaque on the lower back. Which of the following is most strongly associated with this patient's condition? | {
"A": "Cardiac rhabdomyoma",
"B": "Glaucoma",
"C": "Optic glioma",
"D": "Polyostotic fibrous dysplasia",
"E": "Renal cell carcinoma"
} | Cardiac rhabdomyoma | A |
A 55-year-old man presents to urgent care for weakness and weight loss. For the past several months, he has felt progressively weaker and has lost 25 pounds with intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. A few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the most appropriate next step in management? | {
"A": "CT scan of the abdomen and pelvis",
"B": "CT scan of the chest",
"C": "HIDA scan",
"D": "Right upper quadrant ultrasound",
"E": "Smoking cessation advice and primary care follow up"
} | CT scan of the abdomen and pelvis | A |
A 26-year-old woman presents to the emergency department with 1 day of vaginal bleeding and lower abdominal pain. The pain is most pronounced in the lower abdomen and has gotten worse over the past day. Her last menstrual period was 7 weeks ago. She denies any recent abdominal or vaginal trauma. She has no other past medical history and takes no medications. She uses a copper intrauterine device and is in a monogamous relationship. Her temperature is 99°F (37.2°C), blood pressure is 79/50 mmHg, pulse is 135/min, and respirations are 20/min. Physical examination is notable for diffuse abdominal tenderness upon palpation. Pelvic examination demonstrates uterine and adnexal tenderness and uterine bleeding. Laboratory studies are shown below:
Hemoglobin: 9.5 g/dL
Leukocyte count: 6,000/mm^3
Serum beta-human chorionic gonadotropin (hCG): 2,700 IU/L
The patient is started on intravenous fluids. Which of the following is the most appropriate next step in management? | {
"A": "CT of the abdomen and pelvis",
"B": "Laparoscopy",
"C": "Methotrexate therapy",
"D": "Repeat beta-hCG in 48 hours",
"E": "Transvaginal ultrasound"
} | Laparoscopy | B |
A 24-year-old man presents to his primary care physician with left groin pain. The pain started a year ago and has progressed. He now has 8/10 pain when climbing stairs or rising from a seated position. He localizes the pain to the front of his groin. He denies any erythema or swelling. He has a history of hypertension, sickle cell anemia, and a splenectomy. He drinks a glass of wine with dinner every night and took up scuba diving 2 months ago but otherwise does not exercise. His temperature is 97.5°F (36.4°C), blood pressure is 124/68 mmHg, pulse is 82/min, and respirations are 16/min. His body mass index (BMI) is 18.1 kg/m^2. Physical exam reveals left groin pain at the terminal ranges of hip abduction and internal rotation. There is no point tenderness. A radiograph is obtained as in Figure A. Which of the following components of this patient’s history most strongly predisposed him to this condition? | {
"A": "Alcohol use",
"B": "History of sickle cell disease",
"C": "Lack of physical activity",
"D": "Low BMI",
"E": "Scuba diving"
} | History of sickle cell disease | B |
A 30-year-old man is evaluated in the post-anesthesia care unit for neck pain. He underwent a laparoscopic appendectomy and was treated for post-operative nausea and vomiting with metoclopramide. Approximately 20 minutes after receiving the medication, he developed pain and stiffness in his neck and eventually was unable to move his neck. His temperature is 98.6°F (37.0°C), pulse is 90/min, blood pressure is 130/80 mmHg, respirations are 16/min, and oxygen saturation is 98% on room air. Examination reveals an uncomfortable appearing man. His neck is rotated to the right and is unable to return to midline. Examination of the patient is shown in Figure A. Which of the following is the most appropriate next step in management? | {
"A": "Botulinum toxin injection",
"B": "Diphenhydramine",
"C": "Haloperidol",
"D": "Observation",
"E": "Ondansetron"
} | Diphenhydramine | B |
A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications. His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min. His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation. His abdomen is distended and tender in all quadrants, with guarding and rebound present. He also has increased bowel sounds throughout. Laboratory results are as follows:
Hemoglobin: 11 g/dL
Leukocyte count: 16,500/mm^3 with normal differential
Platelets: 250,000/mm^3
Serum:
Creatinine: 1.0 mg/dL
Glucose: 95 mg/dL
Lipase: 45 U/L
Total bilirubin: 0.8 mg/dL
Alkaline phosphatase: 74 U/L
Aspartate aminotransferase (AST, GOT): 32 U/L
Alanine aminotransferase (ALT, GPT): 45 U/L
Lactate: 7.0 mmol/L
Which of the following is the most appropriate next step in management? | {
"A": "Broad-spectrum antibiotics and serial abdominal radiographs",
"B": "CT angiography of the abdomen and pelvis",
"C": "Nasogastric tube placement",
"D": "Supportive care, NPO, and intravenous fluids",
"E": "Urgent surgical intervention"
} | Urgent surgical intervention | E |
A 60-year-old woman presents to the emergency department with back pain after gardening. Her pain is 7/10 in severity, non-radiating, and not relieved by rest. She has never experienced this pain in the past and denies fever, night sweats, unintentional weight loss, and bowel or bladder incontinence. She has hypertension for which she takes hydrochlorothiazide and had a recent asthma flare requiring a prednisone taper. She does not drink alcohol or smoke. Her temperature is 98.6°F (37.0°C), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min. Physical exam reveals an uncomfortable middle-aged woman in no acute distress. There is no tenderness to palpation of the spinous processes. Flexion of the hip with the knee extended while the patient is supine does not elicit any pain, nor does forced dorsiflexion of the foot at terminal hip extension. She has 5/5 strength to hip flexion, extension, abduction, and adduction; knee flexion and extension; and ankle dorsiflexion and plantarflexion bilaterally. Bilateral patellar and Achilles reflexes are 2+. Serum laboratory results are as follows: Hemoglobin: 12.0 g/dL Creatinine: 1.1 mg/dL Ca2+: 10.6 mg/dL Which of the following is the most likely diagnosis? | {
"A": "Herniated disc",
"B": "Lumbosacral strain",
"C": "Multiple myeloma",
"D": "Spondylolisthesis",
"E": "Vertebral compression fracture"
} | Lumbosacral strain | B |
A 4-week-old boy presents with his parents to the pediatrician for a well-child visit. His mother reports he was eating well until 1 week ago when he began vomiting after breastfeeding. His mother has tried increasing the frequency of feeds and decreasing the amount of each feed, but the vomiting seems to be getting worse. The patient now vomits after every feed. The vomitus looks like breast milk. The patient’s mother is exclusively breastfeeding and would prefer not to switch to formula but worries that the patient is not getting the nutrition he needs. Two weeks ago, the patient was in the 75th percentile for weight and 70th for height. He is now in the 60th percentile for weight and 68th percentile for height. His temperature is 98.2°F (36.8°C), blood pressure is 58/37 mmHg, pulse is 144/min, and respirations are 34/min. On physical exam, the patient has dry mucous membranes. His abdomen is soft and non-distended. Which of the following is the most appropriate next step in management? | {
"A": "Abdominal radiograph",
"B": "Abdominal ultrasound",
"C": "Supplement breastfeeding with formula",
"D": "Trial of dairy-free diet",
"E": "Trial of empiric proton pump inhibitor"
} | Abdominal ultrasound | B |
A 75-year-old man presents to the emergency department with fatigue. He has had severe nausea, vomiting, and diarrhea for the past 3 days. Today, his wife noticed that he was confused. The patient has a history of coronary artery disease with a drug-eluting stent placed 1 year ago, obesity, hypertension, and dyslipidemia. He denies chest pain or dyspnea, but complains of diffuse abdominal pain. His temperature is 99.0°F (37.2°C), blood pressure is 100/60 mmHg, pulse is 105/min, and respirations are 22/min. Physical exam reveals a confused man with dry mucous membranes. His abdomen is diffusely tender to palpation. Laboratory studies are ordered and notable for the following:
Serum:
Na+: 147 mEq/L
Cl-: 112 mEq/L
K+: 3.5 mEq/L
HCO3-: 14 mEq/L
BUN: 80 mg/dL
Glucose: 100 mg/dL
Creatinine: 2.1 mg/dL
Troponin: 0.10 mcg/L (normal < 0.01 mcg/L)
An ECG is ordered and is pending. Which of the following is the most appropriate management of this patient's elevated troponin? | {
"A": "Aspirin",
"B": "Aspirin, heparin, clopidogrel, and cardiac catheterization",
"C": "Metoprolol and aspirin",
"D": "Obtain a urinalysis and creatine phosphokinase level",
"E": "Ringer lactate bolus"
} | Ringer lactate bolus | E |
A girl presents to her pediatrician for a well-child visit. Her mother reports that she is eating well at home and sleeping well throughout the night. She can jump and walk up and down stairs with both feet on each step. In the doctor’s office, the patient builds a 6-cube tower and imitates a circle. She seems to have a vocabulary of over 50 words that she uses in 2-word sentences. The patient enjoys playing near other children and sometimes argues over toys with her older brother. Her temperature is 98.6°F (37°C), blood pressure is 92/56 mmHg, pulse is 106/min, and respirations are 23/min. On physical exam, she appears well developed and well nourished, and she is following along her growth curves. The child is assessed as developmentally normal. Which of the following is an additional milestone associated with this child’s age? | {
"A": "Balances on one foot",
"B": "Cuts with scissors",
"C": "Follows two-step commands",
"D": "Points to one body part",
"E": "Turns pages in book"
} | Follows two-step commands | C |
A 41-year-old man presents to his primary care provider with a 2-month history of abdominal pain. He says that the pain “comes and goes” throughout the day and usually lasts 20-30 minutes per episode. The pain is above his umbilicus. He denies any feeling of regurgitation or nighttime cough but endorses nausea. He used to eat 3 large meals per day but has found that eating smaller meals more frequently improves his pain. He tried ibuprofen with food and thinks it helped. He has gained 4 pounds since his last appointment 3 months ago. He denies any diarrhea or change in his stools. He has no known medical history. He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history. He denies any family history of cancer. His temperature is 98.6°F (37°C), blood pressure is 117/72 mmHg, pulse is 72/min, and respirations are 13/min. On physical exam, he is tender to palpation above the umbilicus. Bowel sounds are present. A stool guaiac test is positive. The patient undergoes an endoscopy with a biopsy to diagnose his condition. Which of the following is most likely to be found on histology? | {
"A": "Crypt abscesses in the large intestine",
"B": "Mucosal defect in the stomach",
"C": "Noncaseating granulomas in the small intestine",
"D": "PAS-positive material in the small intestine",
"E": "Urease-producing organism in the small intestine"
} | Urease-producing organism in the small intestine | E |
A 62-year-old man arrives at the emergency room complaining of chest pain and difficulty breathing. He reports that the dyspnea started 2 months ago after he had the flu. At first, the difficulty breathing occurred whenever he went up and down 1 flight of stairs, but the dyspnea progressively worsened since then. This morning, he developed chest pain and difficulty breathing while sitting at the kitchen table. The patient’s medical history is significant for hypertension, type 2 diabetes mellitus, and rheumatoid arthritis. His medications include aspirin, lisinopril, metformin, and sulfasalazine. His temperature is 97°F (36.1°C), blood pressure is 130/78 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 97% O2 on room air. On physical exam, jugular venous distension during both inspiration and expiration, mild abdominal distention, and 2+ bilateral lower extremity edema is noted. A chest radiograph is obtained and the result is shown in Figure A. Which of the following is the most likely cause of this patient's symptoms? | {
"A": "Cardiac tamponade",
"B": "Cirrhosis",
"C": "Constrictive pericarditis",
"D": "Pulmonary arterial hypertension",
"E": "Restrictive cardiomyopathy"
} | Constrictive pericarditis | C |
A 25-year-old woman presents to her primary care physician with joint and muscle pain. She has a general aching/pain in her joints that lasts all day. The pain is constant and is not relieved by rest or activity. She also has pain in her hands at times and occasionally notices trouble swallowing when she is eating. She has a medical history of anxiety and is not currently taking any medications. Her temperature is 98.6°F (37°C), blood pressure is 115/72 mmHg, pulse is 74/min, and respirations are 11/min. On physical exam, the patient is a healthy young woman with a sunburn. Her hands are mildly edematous with the findings in Figure A. Laboratory values are below:
Serum:
Na+: 145 mEq/L
K+: 4.4 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
BUN: 9 mg/dL
Glucose: 70 mg/dL
Creatinine: .7 mg/dL
Ca2+: 10 mg/dL
Mg2+: 1.8 mEq/L
Which of the following antibodies is most likely to aid in making the diagnosis in this patient? | {
"A": "Anti-dsDNA",
"B": "Anti-IgG Fc region",
"C": "Anti-nuclear antibody",
"D": "Anti-ribonuleoprotein",
"E": "Anti-Ro"
} | Anti-ribonuleoprotein | D |
A 32-year-old man presents to the emergency department for evaluation of headache. His symptoms started last night and have persisted. He occasionally has migraine headaches, but he has not had a headache like this in the past. He reports associated nausea, vomiting, fevers, and neck pain. He has a medical history of asthma. His temperature is 100.4°F (38.0°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, he appears uncomfortable. Neurologic exam reveals no focal deficits. There is pain with passive neck flexion. No edema or rashes are noted. Lungs are clear to auscultation bilaterally. Lumbar puncture is performed and CSF results are obtained as shown below. Cerebrospinal fluid (CSF): Cell count: 175/mm^3 RBCs: 0/mm^3 Cl-: 119 mEq/L Glucose: 49 mg/dL Pressure: 150 mmH2O Total protein: 55 mg/dL Based on these results, which of the following is the most appropriate treatment regimen for this patient? | {
"A": "Acyclovir",
"B": "Amphotericin and 5-flucytosine",
"C": "Ceftriaxone and vancomycin",
"D": "Ceftriaxone, vancomycin and steroids",
"E": "Supportive care and monitoring"
} | Supportive care and monitoring | E |
A 44-year-old man presents to the emergency department with palpitations. He has a history of anxiety managed with fluoxetine and lorazepam. He also has hypertension but does not take any medications. Today, his symptoms have been persistent despite taking his medications. He says that he feels lightheaded and can’t walk. His temperature is 98.7°F (37.1°C), blood pressure is 120/72 mmHg, pulse is 183/min, respirations are 25/min, and oxygen saturation is 99% on room air. Physical exam reveals a somnolent and uncomfortable man. His pulse is rapid and regular. An ECG is performed as seen in Figure A. During the exam, the patient states that he feels lightheaded and appears occasionally somnolent. Which of the following is the most appropriate treatment for this patient? | {
"A": "Adenosine",
"B": "Amiodarone",
"C": "Cardioversion",
"D": "Defibrillation",
"E": "Procainamide"
} | Cardioversion | C |
A 53-year-old African-American woman presents to her primary care doctor with increasing difficulty climbing the stairs. She noticed the weakness approximately 3 months ago. It has gotten progressively worse since that time. She has also noticed increasing difficulty combing her hair, standing from a seated position, and experiences muscle aches. Her medical history is significant for hypertension treated with lifestyle modification and gastroesophageal reflux disease (GERD). Her temperature is 98.6°F (37.0°C), blood pressure is 130/65 mmHg, pulse is 80/min, and respirations are 16/min. She has 3/5 strength to shoulder abduction and hip flexion bilaterally. Her strength is 5/5 to wrist extension and ankle plantar flexion. No skin rashes are noted. Which of the following is the most accurate test to confirm this patient’s diagnosis? | {
"A": "Electromyography",
"B": "MRI",
"C": "Muscle biopsy",
"D": "Serum aldolase",
"E": "Serum creatine kinase"
} | Muscle biopsy | C |
A 16-year-old girl who recently immigrated to the United States from Bolivia presents to her primary care physician with a chief complaint of inattentiveness in school. The patient's teacher describes her as occasionally "daydreaming" for periods of time during where the patient does not respond or participate in school activities. Nothing has helped the patient change her behavior, including parent-teacher conferences or punishment. The patient has no other concerns. The only other concern that the patient's mother has is that, upon awakening, she notices that sometimes the patient's arm will jerk back and forth. The patient states she is not doing this intentionally. The patient has an unknown medical history and is currently not on any medications. She is not sexually active and does not intend to become pregnant in the near future. Her temperature is 98.6°F (37°C), blood pressure is 112/74 mmHg, pulse is 63/min, and respirations are 11/min. On physical exam, you note a young, healthy girl whose neurological exam is within normal limits. Which of the following is the most appropriate initial treatment? | {
"A": "Carbamazepine",
"B": "Cognitive behavioral therapy",
"C": "Ethosuximide",
"D": "Lamotrigine",
"E": "Valproic acid"
} | Valproic acid | E |
A 31-year-old man presents to the emergency department for fever, malaise, and cough. For the last week, his cough has been progressively worsening, and he has been noticing blood in his sputum. He denies any recent travel or sick contacts and infrequently smokes cigarettes. Approximately 5 weeks ago, he presented with similar symptoms and was found to have a right upper lobe lung infiltrate, a CD4 count of 40/mm^3, and an HIV viral load of 115,000 copies/mL. He was appropriately treated and discharged home. Four weeks after initiation of treatment, his CD4 count was over 400/mm^3 and HIV viral load was negligible. His temperature today is 102°F (38.9°C), blood pressure is 130/90 mmHg, pulse is 100/min, and respirations are 20/min. A radiograph of the chest demonstrates new nodules in the left upper lobe and hilar adenopathy. Which of the following is the most appropriate next step in management? | {
"A": "Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies",
"B": "Determine drug sensitivities against the patient’s pulmonary infection",
"C": "Discontinue antimicrobial treatment",
"D": "Obtain a D-dimer level",
"E": "Start high-dose glucocorticoid treatment and discontinue antiretroviral therapy"
} | Continue current anti-retroviral treatment, antimicrobial, and anti-tuberculoid therapies | A |
A 57-year-old woman presents to her primary care physician with weakness for the past 6 months with symptoms that have worsened recently. She feels fatigued, depressed, and has gained 10 pounds which she attributes to feeling too weak to go to the gym. She was recently treated for an ear infection with an antibiotic which she completed 3 weeks ago, and experienced a rash which she believes was an allergic reaction to her treatment. The patient has a medical history of diabetes mellitus that is well-controlled with insulin and metformin. She has been admitted multiple times for hypoglycemia secondary to missing meals. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 80/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for 2/5 strength in the patient's upper and lower extremities, sparse fine hair on her body, and a rash on her face and arms. Laboratory values are ordered as seen below. Serum: Na+: 139 mEq/L K+: 3.3 mEq/L Cl-: 100 mEq/L HCO3-: 25 mEq/L BUN: 20 mg/dL Glucose: 70 mg/dL Creatinine: 1.1 mg/dL Ca2+: 10.2 mg/dL AST: 12 U/L ALT: 10 U/L A muscle biopsy is obtained as seen in Figure A. Which of the following is the most likely explanation for this patient's presentation? | {
"A": "Dermatomyositis",
"B": "Hypokalemia",
"C": "Hypothyroidism",
"D": "Inclusion body myositis",
"E": "Polymyositis"
} | Inclusion body myositis | D |
A 6-month-old girl is brought to the pediatrician by her father for a scheduled check-up. She was in her usual state of health until 6 weeks ago when she was hospitalized for bacterial pneumonia. She received amoxicillin and had a resolution of her symptoms. Her father reports that she seems “back to normal.” She can roll over by herself and can sit up without support. She often babbles but sometimes does make identifiable sounds like “dada” and “baba.” They recently started feeding her mushy cereal, which she seems to like but occasionally spits up. She has started teething and sometimes becomes “fussy.” Vital signs are within normal limits. A physical examination is unremarkable. The patient’s father brought a 4-week follow-up chest radiograph taken at the hospital, as shown in Figure A. Which of the structures labeled in Figure A would be most likely to change in response to another infectious illness? | {
"A": "A",
"B": "B",
"C": "C",
"D": "D",
"E": "E"
} | A | A |
A 57-year-old man presents to the emergency department for weight loss and abdominal pain. The patient has felt steadily more fatigued over the past month and has lost 22 pounds without effort. Today, he fainted prompting his presentation. The patient has no significant medical history. He does have a 33-pack-year smoking history and drinks 4 to 5 alcoholic drinks per day. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is very thin and appears pale. Stool fecal occult blood testing is positive. A CT scan of the abdomen is performed demonstrating a mass in the colon with multiple metastatic lesions scattered throughout the abdomen. The patient is informed of his diagnosis of metastatic colon cancer. When the patient conveys the information to his family, he focuses his efforts on discussing the current literature in the field and the novel therapies that have been invented. He demonstrates his likely mortality outcome which he calculated using the results of a large multi-center study. Which of the following is this patient most likely demonstrating? | {
"A": "Dissociation",
"B": "Intellectualization",
"C": "Optimism",
"D": "Pessimism",
"E": "Rationalization"
} | Intellectualization | B |
A 55-year-old man presents to his primary care physician with persistent symptoms of depression. He started taking fluoxetine 3 weeks ago when he was diagnosed with major depressive disorder after a divorce. Since then, he notes that his symptoms are roughly unchanged. His other medications include albuterol. His temperature is 99.3°F (37.4°C), blood pressure is 132/88 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals a depressed affect. His neurologic exam is non-focal. A serum thyroid stimulating hormone (TSH) resulted from his last visit and is noted to be 4.8 µU/mL (normal: 0.5-5 µU/mL). Which of the following is the most appropriate next step in management? | {
"A": "Administer levothyroxine",
"B": "Change medication to bupropion",
"C": "Change medication to escitalopram",
"D": "Increase dose of current medication",
"E": "Maintain dose of current medication"
} | Maintain dose of current medication | E |
A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. The symptoms began towards the end of running a marathon and persisted after finishing the race. The patient is otherwise healthy and has no other medical problems. His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended and tender abdomen. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis? | {
"A": "Cecal volvulus",
"B": "Ileus",
"C": "Ogilvie syndrome",
"D": "Sigmoid volvulus",
"E": "Small bowel obstruction"
} | Cecal volvulus | A |
A 26-year-old woman presents to the emergency department because she feels as though her heart is "beating out of her chest." She states that she feels well apart from the discomfort of that sensation. Her temperature is 97.9°F (36.6°C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxygen saturation is 98% on room air. An ECG is obtained as seen in Figure A. After unsuccessful attempts at vagal maneuvers, the emergency physician administers an IV medication. The effect of the medication wears off in seconds. Which of the following is a potential side effect of this medication? | {
"A": "Disulfiram-like reaction",
"B": "Flushing",
"C": "Photosensitivity",
"D": "Seizure",
"E": "Tachycardia"
} | Flushing | B |
A 69-year-old man presents to his primary care physician for a general checkup. The patient works as a farmer and gardens in his spare time. He has a medical history of poorly managed type 2 diabetes mellitus and irritable bowel syndrome. His current medications include lisinopril, metformin, insulin, fiber supplements, and a multivitamin. On physical exam, there is a calm, obese gentleman. Inspection of the patient's scalp reveals the finding shown in Figure A. The patient is sent home and instructed to keep a blood glucose journal. Three months later, the patient returns with his glucose journal. In addition, he complains of a cut on his scalp that is not seeming to heal. The patient's glucose journal reveals an average blood glucose of 175 mg/dL. His temperature is 98.8°F (37.1°C), blood pressure is 134/86 mmHg, pulse is 80/min, and respirations are 13/min. On inspection of the patient's scalp, the finding in Figure B is noted. Which of the following is the most likely diagnosis? | {
"A": "Actinic keratosis",
"B": "Basal cell carcinoma",
"C": "Melanoma",
"D": "Poor wound healing secondary to diabetes",
"E": "Squamous cell carcinoma"
} | Squamous cell carcinoma | E |
A 25-year-old woman presents for a new patient physical exam. Aside from occasional shin splints, she has a relatively unremarkable medical history. She takes oral contraceptive pills and a multivitamin daily. All of her age appropriate immunizations are up to date. Her periods have been regular, occurring once every 28 to 30 days with normal flow. She is sexually active with 2 partners, who use condoms routinely. Her prior pap smear was performed last year and was normal. Her mother has diabetes and coronary artery disease, and her father passed away at age 45 after being diagnosed with colon cancer at age 40. Her grand-aunt underwent bilateral mastectomies after being diagnosed with breast cancer at age 60. Her temperature is 36.7°C (98°F), blood pressure is 115/80 mmHg, pulse is 65/min, respirations are 12/min, and oxygen saturation is 100% on room air. Her physical exam is within normal limits. Which of the following is the most appropriate recommendation for this patient? | {
"A": "Colonoscopy in 5 years",
"B": "Colonoscopy in 10 years",
"C": "Mammogram now",
"D": "Pap smear in 5 years",
"E": "Pap smear with human papillomavirus (HPV) DNA testing now"
} | Colonoscopy in 5 years | A |
A 67-year-old man is seen on the surgical floor after a transplant procedure. The previous day, the patient had a renal transplant from a matched donor. He is currently recovering and doing well. The patient has a medical history of IV drug use, diabetes mellitus, oral cold sores, hypertension, renal failure, and dyslipidemia. The patient's current medications include lisinopril, atorvastain, insulin, and aspirin. Prior to the procedure, he was also on dialysis. The patient is started on cyclosporine. The patient successfully recovers over the next few days. His temperature is 98.5°F (36.9°C), blood pressure is 121/76 mmHg, pulse is 70/min, and respirations are 13/min. Which of the following medications should be started in this patient? | {
"A": "Azithromycin",
"B": "Low dose acyclovir",
"C": "Penicillin",
"D": "TMP-SMX",
"E": "Valacyclovir"
} | TMP-SMX | D |
An 83-year-old man is brought to the emergency department by his daughter due to confusion over the last 2 weeks. The patient initially became less talkative than usual before starting to confuse her with her sister. The patient also could not remember what day of the week it was and he was out of groceries and likely had been for several days when visited. While she was talking to him, he fell asleep and was difficult to rouse. The patient is unable to provide a clear history. He has a medical history of hypertension, glaucoma, and osteoarthritis in his left knee that requires him to walk with a cane. He takes hydrochlorothiazide, timolol eyedrops, and occasional acetaminophen. His temperature is 98.5° F (36.9° C), blood pressure is 122/74 mmHg, pulse is 75/min, and respirations are 14/min. The patient is lethargic but arousable, oriented only to person, and disheveled. Neurologic exam reveals intact cranial nerves, 1+ deep tendon reflexes throughout, and 4/5 strength in all extremities. There is a 3 x 5 cm green-blue area of ecchymosis on the lateral aspect of his left knee. A CT of the head without contrast is performed and shown in Figure A. Which of the following factors plays the earliest role in the progression towards this patient’s presentation? | {
"A": "Aneurysmal rupture",
"B": "Cerebral atrophy",
"C": "Elderly abuse",
"D": "Hypertension",
"E": "Increased cerebrospinal fluid"
} | Cerebral atrophy | B |
A 45-year-old African American woman presents to her primary care physician for not feeling well. She states she has had a cough for the past week. She also has abdominal pain and trouble focusing that has been worsening and has lost 5 pounds recently. Her gastroesophageal reflux disease (GERD) has been poorly controlled recently. The patient is a non-smoker and has a history of GERD for which she takes antacids. Her temperature is 98.6°F (37°C), blood pressure is 115/71 mmHg, pulse is 72/min, and respirations are 12/min. A physical exam is within normal limits. Laboratory studies are ordered and are below:
Serum:
Na+: 139 mEq/L
K+: 4.1 mEq/L
Cl-: 101 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 12 mg/dL
Glucose: 70 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 12.5 mg/dL
Alkaline phosphatase: 150 U/L
Phosphorus: 2.0 mg/dL
Urine:
Color: amber
Nitrites: negative
Sodium: 5 mmol/24 hours
Red blood cells: 0/hpf
Which of the following is the most likely explanation of this patient's current presentation? | {
"A": "Antacid overuse",
"B": "Increased 1,25-dihydroxyvitamin D",
"C": "Increased parathyroid hormone",
"D": "Malignancy",
"E": "Viral illness"
} | Increased parathyroid hormone | C |
A 57-year-old man is brought to a neurologist by his wife for abnormal behavior. He was normal until around 3 months ago when he started forgetting important meetings and misplacing items around the house. One month ago, the patient was fired from his job as a software engineer after attempting to grope a coworker. The patient expresses frustration that he is no longer able to concentrate enough to enjoy his hobby of solving puzzles. His medical history is significant for gastroesophageal reflux disease for which he takes omeprazole. He has no family history of neurologic disease. His temperature is 98.6°F (37.0°C), blood pressure is 120/75 mmHg, pulse is 70/min, and respirations are 16/min. During the examination, the patient’s cell phone rings unexpectedly causing the patient to suddenly jerk his arms and legs. Further diagnostic investigation is performed which reveals an elevated 14-3-3 protein on cerebrospinal fluid analysis. Which of the following is the most likely diagnosis? | {
"A": "Alzheimer disease",
"B": "Creutzfeldt-Jacob disease",
"C": "Dementia with Lewy bodies",
"D": "Frontotemporal dementia",
"E": "Subcortical leukoencephalopathy"
} | Creutzfeldt-Jacob disease | B |
A 24-year-old man presents to the emergency room after a motor vehicle collision. He was the driver in a head-on collision and was not wearing a seatbelt. The patient is acutely intoxicated and is attempting to attack the nurses. Soon after presentation, he is sedated, paralyzed, and intubated. His medical history is unknown. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 32/min, and oxygen saturation is 98% on room air. Physical exam is notable for jugular venous distension. An electrocardiogram (ECG) is performed as seen in Figure A. Which of the following is the most appropriate next step in management? | {
"A": "Needle thoracostomy",
"B": "Packed red blood cells",
"C": "Pericardial window",
"D": "Pericardiocentesis",
"E": "Tube thoracostomy"
} | Pericardiocentesis | D |
A 68-year-old woman presents to her primary care provider for dizziness. She often feels lightheaded and like she may “pass out” but never actually loses consciousness. She denies dyspnea on exertion or orthopnea. The patient had a myocardial infarction 6 months ago, and she now has multiple drug-eluting stents. Her ECG upon discharge from that hospitalization was normal. The patient has been taking all of her medications as instructed. Her medical history is otherwise significant for rheumatoid arthritis and migraines. Her home medications include methotrexate, atorvastatin, clopidogrel, and aspirin. Her temperature is 98.6°F (37°C), blood pressure is 118/75 mmHg, pulse is 92/min, and respirations are 12/min. On physical exam, she has an irregular heartbeat with normal cardiac sounds. Her abdomen is non-distended and she has mild lower extremity edema. Her current ECG can be seen in Figure A. Which component of the cardiac conduction system is most likely affected in this patient? | {
"A": "Atrioventricular node",
"B": "Bundle branches",
"C": "Bundle of His",
"D": "Purkinje fibers",
"E": "Sinoatrial node"
} | Atrioventricular node | A |
A 69-year-old man presents to his primary care provider for a general checkup. He has a medical history of type 2 diabetes mellitus, hypertension, depression, obesity, and a myocardial infarction 7 years ago. The patient's prescribed medications are metoprolol, aspirin, lisinopril, hydrochlorothiazide, fluoxetine, metformin, and insulin. The patient has not been filling his prescriptions regularly and can not remember what medications he has been taking. His temperature is 99.5°F (37.5°C), pulse is 96/min, blood pressure is 180/120 mmHg, respirations are 18/min, and oxygen saturation is 97% on room air. Laboratory values are obtained and the results are shown below:
Serum:
Na+: 139 mEq/L
K+: 4.3 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
BUN: 7 mg/dL
Glucose: 170 mg/dL
Creatinine: 1.2 mg/dL
Which of the following cardiac findings would be expected on physical exam? | {
"A": "Fixed splitting of S1 and S2",
"B": "Heart sound after S2",
"C": "Heart sound before S1",
"D": "Holosystolic murmur at the apex",
"E": "Normal S1 and S2"
} | Heart sound before S1 | C |
A 66-year-old man presents to the clinic with a 6-week history of bloody stools. He describes the blood as bright red wisps that float on the surface of the stool. He has no pain with bowel movements but notes on occasion he may strain. He does not endorse fatigue, fever, constipation, diarrhea, nausea, vomiting, abdominal pain, weight loss, or dyspnea. His last colonoscopy was 3 years prior to presentation and was benign. He has a medical history significant for hypertension that is well-controlled with lisinopril. He had an uncomplicated appendectomy when he was 23 years old. He has no family history of gastrointestinal malignancy. His temperature is 98.6°F (37.0°C), blood pressure is 140/90 mmHg, pulse is 76/min, and respirations are 16/min. On physical exam, the patient's abdomen is soft, non-distended, and non-tender with normal bowel sounds and without organomegaly or masses. The anus is patent without fissures, hemorrhoids, or skin tags. Which of the following is the most appropriate next step in management? | {
"A": "Colonoscopy",
"B": "Computerized tomography scan of abdomen and pelvis",
"C": "Increase fiber in diet",
"D": "Observation",
"E": "Sigmoidoscopy"
} | Colonoscopy | A |
A 6-week-old girl presents with her parents to the pediatrician for blood-streaked diapers. The patient is breastfed every 2-3 hours and voids 10-12 times daily. The patient previously had several soft stools per day that ranged in color from mustard yellow to dark green. Over the past 2 days, the patient’s stools have become looser and streaked with blood. The patient has also regurgitated several of her feedings in the last few days. Neither the vomit nor bloody stools have seemed to bother the patient. The patient’s weight continues to trend along the 50th percentile. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 66/51 mmHg, pulse is 127/min, and respirations are 26/min. On physical exam, the patient appears well nourished and is cooing. Her abdomen is soft and non-tender. Physical exam reveals the finding seen in Figure A. Which of the following is the most likely etiology of this patient’s presentation? | {
"A": "Congenital enzyme deficiency",
"B": "Hypertrophy of sphincter muscle",
"C": "Non-IgE-mediated immunologic reaction",
"D": "Passage of gastric contents into esophagus",
"E": "Telescoping of the intestine"
} | Non-IgE-mediated immunologic reaction | C |
A 22-year-old man presents to the emergency department with difficulty breathing. He has experienced similar symptoms before. Today, he was hit in the face with a football, followed by significant swelling of his lips and tongue. The patient speaks with a muffled voice. His temperature is 98.1°F (36.7°C), blood pressure is 120/83 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals swollen lips and a protruding, enlarged tongue. His breath sounds are clear. He demonstrates no rash and his abdomen is soft and nontender. Which of the following is the most effective therapy for this patient? | {
"A": "Dexamethasone",
"B": "Diphenhydramine",
"C": "Epinephrine",
"D": "Fresh frozen plasma",
"E": "Tranexamic acid"
} | Fresh frozen plasma | D |
A 25-year-old man presents to his primary care physician for trouble with focus and concentration. He states that he lives at home with his parents his entire life and recently was able to get a job at a local factory. Ever since the patient started working, he has had trouble focusing on his job. He is unable to stay focused on any task. His boss often observes him "daydreaming" with a blank stare off into space. His boss will have to yell at him to startle him back to work. The patient states that he feels fatigued all the time and sometimes will suddenly fall asleep while operating equipment. He has tried going to bed early for the past month but is unable to fall asleep until 2 hours prior to his alarm. His temperature is 98.6°F (37°C), blood pressure is 112/68 mmHg, pulse is 81/min, and respirations are 12/min. A physical exam is within normal limits. The patient fears that if this continues he will lose his job. Which of the following is the most appropriate initial step in management? | {
"A": "Bright light therapy and decreased light at night",
"B": "Ethosuximide",
"C": "Modafinil",
"D": "Polysomnography",
"E": "Zolpidem"
} | Bright light therapy and decreased light at night | A |
A 68-year-old man presents for evaluation by a neurologist for an involuntary hand tremor that started approximately 3 months ago. The shaking improves when he reaches for objects but returns when he is not using his hand. His temperature is 98.6°F (37.0°C), blood pressure is 115/70 mmHg, pulse is 70/min, and respirations are 12/min. His left hand exhibits a 4-6 Hz tremor when resting on his lap. The tremor extinguishes with voluntary movement. In addition, his left upper extremity has increased tone with passive range of motion. Which of the following is the most likely diagnosis? | {
"A": "Cerebellar stroke",
"B": "Essential tremor",
"C": "Huntington disease",
"D": "Lacunar stroke",
"E": "Parkinson disease"
} | Parkinson disease | E |
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