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### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Sulfasalazine | Q:A 34-year-old male comes to his family physician with complaints of joint pain that has been present for over 7 weeks. Prior to the onset of his arthritis, he recalls having a gastrointestinal infection which caused mild diarrhea and abdominal cramps. He recovered well and had no issues until his joint pain started. A prescription for naproxen was previously prescribed but he still does not feel well. He has no significant past medical or family history. On physical examination, his blood pressure is 120/78 mm Hg, respirations are 17/min, pulse is 64/min, and temperature is 36.7°C (98.0°F). Which of the following therapies is likely to be most beneficial in treating this patient’s condition??
{'A': 'Diclofenac', 'B': 'Sulfasalazine', 'C': 'Methotrexate', 'D': 'Ketoprofen', 'E': 'Ceftriaxone'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Neuroleptic malignant syndrome | Q:A 22-year-old man presents to the emergency department with a 2-day history of fever and altered mentation. He reports fever without chills and rigors and denies sore throat, abdominal pain, headache, loose stool, burning micturition, or seizures. He has a history of tics and is currently on a low dose of haloperidol. At the hospital, his temperature is 39.6°C (103.2°F); the blood pressure is 126/66 mm Hg, and the pulse is 116/min. He is profusely sweating and generalized rigidity is present. He is confused and disoriented. He is able to move all his limbs. Normal deep tendon reflexes are present with bilateral downgoing plantar responses. A brain MRI is unremarkable. Urine toxicology is negative. The white blood cell count is 14,700/mm3. Creatine kinase is 5600 U/L. Lumbar puncture is performed and cerebrospinal fluid (CSF) studies show:
CSF opening pressure 22 cm H20
CSF white blood cells 4 cells/mm3
CSF red blood cells 0 cells/mm3
CSF glucose 64 mg/dL
CSF protein 48 mg/dL
Serum glucose 96 mg/dL
What is the most likely diagnosis??
{'A': 'Acute disseminated encephalomyelitis', 'B': 'Cerebral venous sinus thrombosis', 'C': 'Encephalitis', 'D': 'Meningitis', 'E': 'Neuroleptic malignant syndrome'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Lamin | Q:A 10-month-old boy is brought to the physician by his mother for evaluation of abnormal growth and skin abnormalities. His mother has also noticed that his eyes do not fully close when sleeping. He is at the 24th percentile for height, 17th percentile for weight, and 29th percentile for head circumference. Physical examination shows wrinkled skin, prominent veins on the scalp and extremities, and circumoral cyanosis. Genetic testing shows a point mutation in a gene that encodes for a scaffold protein of the inner nuclear membrane. The mutation causes a deformed and unstable nuclear membrane, which leads to premature aging. Which of the following is most likely to be the defective protein??
{'A': 'Desmin', 'B': 'Nesprin', 'C': 'Vimentin', 'D': 'Lamin', 'E': 'Plectin\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Inhibition of the globus pallidus internus | Q:A 64-year-old man presents to his primary care physician because of a tremor that he has developed over the last several months. He says that the tremor is worst when he is resting but becomes better when he engages in movements such as picking up the remote for his TV. His wife also says that his movements have become slower over the last few months. Physical exam reveals increased resistance to passive motion of his extremities. Gait exam also shows trouble with starting movement and short, shuffling steps. The most likely cause of this patient's symptoms involve the degeneration of a certain subset of neurons. When the substance released by these neurons interact with a G-alpha-s coupled receptor, which of the following effects occurs??
{'A': 'Inhibition of the globus pallidus externus', 'B': 'Inhibition of the globus pallidus internus', 'C': 'Stimulation of the globus pallidus externus', 'D': 'Stimulation of the globus pallidus internus', 'E': 'Stimulation of the subthalamic nucleus'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: The inflammation is due to obstruction of dermal lymphatic vessels. | Q:A 49-year-old woman presents to her physician with complaints of breast swelling and redness of the skin over her right breast for the past 1 month. She also mentions that the skin above her right breast appears to have thickened. She denies any pain or nipple discharge. The past medical history is significant for a total abdominal hysterectomy at 45 years of age. Her last mammogram 1 year ago was negative for any pathologic changes. On examination, the right breast was diffusely erythematous with gross edema and tenderness and appeared larger than the left breast. The right nipple was retracted and the right breast was warmer than the left breast. No localized mass was palpated. Which of the following statements best describes the patient’s most likely condition??
{'A': 'It is a benign lesion.', 'B': 'The inflammation is due to obstruction of dermal lymphatic vessels.', 'C': 'The lesion expresses receptors for estrogen and progesterone.', 'D': 'The lesion is due to Streptococcal infection.', 'E': 'It shows predominant lymphatic spread.'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Plan for oxytocin administration | Q:A 36-year-old primigravid woman at 26 weeks' gestation comes to the physician complaining of absent fetal movements for the last 2 days. Pregnancy was confirmed by ultrasonography 14 weeks earlier. She has no vaginal bleeding or discharge. She has a history of type 1 diabetes mellitus controlled with insulin. Vital signs are all within the normal limits. Pelvic examination shows a soft, 2-cm long cervix in the midline with a cervical os measuring 3 cm and a uterus consistent in size with 24 weeks' gestation. Transvaginal ultrasonography shows a fetus with no cardiac activity. Which of the following is the most appropriate next step in management??
{'A': 'Perform cesarean delivery', 'B': 'Plan for oxytocin administration', 'C': 'Administer magnesium sulfate', 'D': 'Perform weekly pelvic ultrasound', 'E': 'Perform dilation and curettage\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Poor oropharyngeal tone | Q:A 63-year-old man presents to his primary care physician complaining of excessive daytime sleepiness. He explains that this problem has worsened slowly over the past few years but is now interfering with his ability to play with his grandchildren. He worked previously as an overnight train conductor, but he has been retired for the past 3 years. He sleeps approximately 8-9 hours per night and believes his sleep quality is good; however, his wife notes that he often snores loudly during sleep. He has never experienced muscle weakness or hallucinations. He has also been experiencing headaches in the morning and endorses a depressed mood. His physical exam is most notable for his large body habitus, with a BMI of 34. What is the best description of the underlying mechanism for this patient's excessive daytime sleepiness??
{'A': 'Insufficient sleep duration', 'B': 'Circadian rhythm sleep-wake disorder', 'C': 'Poor oropharyngeal tone', 'D': 'Deficiency of the neuropeptides, orexin-A and orexin-B', 'E': 'Psychiatric disorder'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Azithromycin therapy | Q:A previously healthy 5-year-old boy is brought to the physician with a recurring fever and malaise for 3 weeks. He has also had fatigue and loss of appetite. He initially presented 2 weeks ago with a maculopapular rash that has since resolved. At the time, he was given a prescription for amoxicillin-clavulanate. He denies sore throat or myalgias. He is home-schooled and has had no sick contacts. There are no pets at home, but he often visits a feline animal shelter where his mother volunteers. His temperature is 38.4°C (101.2°F). Physical examination shows a 1-cm papular lesion on the back of the right hand. He also has tender, bulky lymphadenopathy of the axillae and groin. Which of the following is the most appropriate next step in management??
{'A': 'Doxycycline therapy', 'B': 'Pyrimethamine therapy', 'C': 'Itraconazole therapy', 'D': 'Azithromycin therapy', 'E': 'Streptomycin therapy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Nightmare disorder | Q:An 8-year-old girl is brought to the physician by her parents because of difficulty sleeping. One to two times per week for the past 2 months, she has woken up frightened in the middle of the night, yelling and crying. She has not seemed confused after waking up, and she is consolable and able to fall back asleep in her parents' bed. The following day, she seems more tired than usual at school. She recalls that she had a bad dream and looks for ways to delay bedtime in the evenings. She has met all her developmental milestones to date. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis??
{'A': 'Sleep terror disorder', 'B': 'Post-traumatic stress disorder', 'C': 'Normal development', 'D': 'Nightmare disorder', 'E': 'Separation anxiety disorder\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Trimethoprim-sulfamethoxazole intravenously | Q:A 56-year-old man who underwent kidney transplantation 6 months ago, presents to the physician because of fever, dyspnea, non-productive cough, and lethargy. He is on no other medications apart from immunosuppressive therapy. On physical examination, the vital signs include: pulse 110/min, blood pressure 126/76 mm Hg, respirations 26/min, oxygen saturation 80% at room air, and temperature 37.7°C (99.9°F). Chest auscultation is normal except for occasional bilateral wheezes. An X-ray of the chest shows diffuse interstitial infiltrates. Bronchoalveolar lavage is performed and methenamine silver staining confirms a parasitic infestation. Which of the following is the most appropriate pharmacotherapy for the patient??
{'A': 'Intravenous pentamidine', 'B': 'Trimethoprim-sulfamethoxazole intravenously', 'C': 'Trimethoprim-sulfamethoxazole orally', 'D': 'High-dose corticosteroids and bronchodilators', 'E': 'Oral dapsone + trimethoprim'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Exercise and smoking cessation | Q:A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms??
{'A': 'Balloon angioplasty with stenting', 'B': 'Exercise and smoking cessation', 'C': 'Femoral-popliteal bypass', 'D': 'Lisinopril and atorvastatin', 'E': 'Lovenox and atorvastatin'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Lower spinal surgery | Q:A 30-year-old woman, gravida 2, para 1, comes to the physician because she had a positive pregnancy test at home. During the last two weeks, she has had nausea and two episodes of non-bloody vomiting. She also reports increased urinary frequency. Her pregnancy and delivery of her first child were uncomplicated. Last year, she had two episodes of grand-mal seizure. She is sexually active with her husband and they use condoms inconsistently. She does not smoke or drink alcohol. She does not use illicit drugs. Current medications include valproic acid and a multivitamin. Her vital signs are within normal limits. Physical examination shows no abnormalities. A urine pregnancy test is positive. The child is at increased risk for requiring which of the following interventions??
{'A': 'Cochlear implantation', 'B': 'Kidney transplantation', 'C': 'Respiratory support', 'D': 'Lower spinal surgery', 'E': 'Dental treatment'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: CT angiography of the abdomen | Q:A 71-year-old man comes to the physician accompanied by his wife because of a 6-month history of worsening episodic upper abdominal pain and an 8-kg (17.6-lb) weight loss. The pain is dull, nonradiating, worse after eating, and occasionally associated with bloating and diarrhea. His symptoms have not improved despite 4 weeks of treatment with omeprazole. He attributes his weight loss to recently eating very small portions and avoiding fatty foods. He has hypertension and hypercholesterolemia. He underwent a coronary artery bypass graft operation for coronary artery disease 8 years ago. Current medications include lisinopril, metoprolol, atorvastatin, and aspirin. He has smoked a pack of cigarettes daily for 20 years and drinks 1–2 beers daily. His pulse is 79/min and blood pressure is 138/89 mm Hg. Examination shows a soft abdomen without tenderness to palpation or guarding. Which of the following is most likely to confirm the diagnosis??
{'A': 'Serum CA 19-9', 'B': 'Right upper quadrant abdominal ultrasound', 'C': 'CT angiography of the abdomen', 'D': 'Endoscopic retrograde cholangiography', 'E': 'Upper endoscopy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Central catheter-related bacteremia | Q:Five days after admission into the ICU for drug-induced acute kidney injury, a 27-year-old woman develops fever. She is currently on a ventilator and sedatives. Hemodialysis is performed via a catheter placed in the right internal jugular vein. Feeding is via a nasogastric tube. An indwelling urinary catheter shows minimum output. Her blood pressure is 85/45 mm Hg, the pulse is 112/min, the respirations are 32/min, and the temperature is 39.6°C (103.3°F). The examination of the central catheter shows erythema around the insertion site with no discharge. Lung auscultation shows rhonchi. Cardiac examination shows no new findings. A chest CT scan shows bilateral pleural effusions with no lung infiltration. Empirical antibiotic therapy is initiated. Blood cultures obtained from peripheral blood and the catheter tip show S. aureus with a similar antibiogram. Urinary culture obtained from the indwelling catheter shows polymicrobial growth. Which of the following best explains this patient’s recent findings??
{'A': 'Catheter-associated urinary tract infection', 'B': 'Central catheter-related bacteremia', 'C': 'Endocarditis', 'D': 'Naso-gastric tube sinusitis', 'E': 'Ventilator-associated pneumonia'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Abdominal aortic aneurysm | Q:A 70-year-old man presents for his annual check-up. He says he feels well except for occasional abdominal pain. He describes the pain as 4/10–5/10 in intensity, diffusely localized to the periumbilical and epigastric regions, radiating to the groin. The pain occurs 1–2 times a month and always subsides on its own. The patient denies any recent history of fever, chills, nausea, vomiting, change in body weight, or change in bowel and/or bladder habits. His past medical history is significant for hypertension, hyperlipidemia, and peripheral vascular disease, managed with lisinopril and simvastatin. The patient reports a 40-pack-year smoking history and 1–2 alcoholic drinks a day. The blood pressure is 150/100 mm Hg and the pulse is 80/min. Peripheral pulses are 2+ bilaterally in all extremities. Abdominal exam reveals a bruit in the epigastric region along with mild tenderness to palpation with no rebound or guarding. There is also a pulsatile abdominal mass felt on deep palpation at the junction of the periumbilical and the suprapubic regions. The remainder of the physical exam is normal. Laboratory studies show:
Serum total cholesterol 175 mg/dL
Serum total bilirubin 1 mg/dL
Serum amylase 25 U/L
Serum alanine aminotransferase (ALT) 20 U/L
Serum aspartate aminotransferase (AST) 16 U/L
Which of the following is the most likely diagnosis in this patient??
{'A': 'Abdominal aortic aneurysm', 'B': 'Acute pancreatitis', 'C': 'Mesenteric ischemia', 'D': 'Acute gastritis', 'E': 'Diverticulitis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Dilated right ventricular cavity | Q:Six days after undergoing a left hemicolectomy for colorectal carcinoma, a 59-year-old man collapses in the hospital hallway and is unconscious for 30 seconds. Afterwards, he complains of shortness of breath and chest pain with deep inhalation. He has hypertension and hyperlipidemia. He smoked one pack of cigarettes daily for 35 years but quit prior to admission to the hospital. He does not drink alcohol. He is in distress and appears ill. His temperature is 36.5°C (97.7°F), blood pressure is 80/50 mm Hg, and pulse is 135/min and weak. Oxygen saturation is 88% on room air. Physical examination shows elevated jugular venous distention. Cardiac examination shows a regular, rapid heart rate and a holosystolic murmur that increases during inspiration. His abdomen is soft and mildly tender to palpation around the surgical site. Examination of his extremities shows pitting edema of the left leg. His skin is cold and clammy. Further examination is most likely to reveal which of the following findings??
{'A': 'Rapid, aberrant contractions of the atria', 'B': 'Stenosis of the carotid arteries', 'C': 'Dilated right ventricular cavity', 'D': 'Anechoic space between pericardium and epicardium', 'E': 'Reduced regional ventricular wall motion'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Prednisone | Q:A 35-year-old woman presents to her physician with a complaint of pain and stiffness in her hands. She says that the pain began 6 weeks ago a few days after she had gotten over a minor upper respiratory infection. She admits that the pain is worse in the morning, and she occasionally notes subjective fever but has not taken her temperature. She also admits that her appetite has mildly decreased, but she denies any change in weight. The pain is partially alleviated by ibuprofen, but she has been unsatisfied with the results. She is concerned about her condition as it makes caring for her two young children very difficult. Temperature is 99.4°F (37.4°C), blood pressure is 119/73 mmHg, pulse is 75/min, and respirations are 18/min. Physical examination demonstrates swelling and tenderness over the wrists and metacarpophalangeal joints bilaterally. Bilateral radiographs of the hands demonstrate mild periarticular osteopenia around the left fifth metacarpophalangeal joint. Which of the following is the next best step in management of this patient's acute symptoms??
{'A': 'Anakinra', 'B': 'Etanercept', 'C': 'Methotrexate', 'D': 'Reassurance', 'E': 'Prednisone'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Embryonal carcinoma | Q:A 15-year-old girl is brought to the physician because of abnormal vaginal bleeding for the past 2 months. Apart from the past 2 months, she has had regular menstrual cycles. She had menarche at the age of 13. She has no personal or family history of any serious illnesses. She takes no medications. Her vital signs are within normal limits. Physical examination shows no abnormal findings. Laboratory studies show elevated serum beta-HCG and AFP levels. An abdominal ultrasound shows a predominantly solid mass in the left ovary. The right ovary and the uterus show no abnormal findings. Which of the following ovarian tumors best explains these findings??
{'A': 'Corpus luteum cyst', 'B': 'Embryonal carcinoma', 'C': 'Fibromas', 'D': 'Krukenberg tumor', 'E': 'Serous cystadenoma'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: I, IV, V | Q:A 2-year-old boy presents with a swollen face and irritability. The patient's mother reports his urine was red this morning. 3 weeks ago, he presented to this same clinic with a ‘sandpaper’ rash and a red tongue with patchy hyperplastic fungiform papillae for which he was given broad-spectrum antibiotics. Laboratory tests reveal proteinuria, elevated antistreptolysin O, and decreased serum C3. Which of the following conditions mentioned below are triggered by a similar mechanism?
I. Arthus reaction
II. Myasthenia gravis
III. Acute rheumatic fever
IV. Polyarteritis nodosa
V. Rheumatoid arthritis?
{'A': 'I, II', 'B': 'III, IV', 'C': 'I, IV, V', 'D': 'II, III, IV', 'E': 'I, IV, V'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: A drug that blocks dopamine 2 receptors | Q:A 37-year-old woman presents to the general medical clinic with a chief complaint of anxiety. She has been having severe anxiety and fatigue for the past seven months. She has difficulty concentrating and her work has suffered, and she has also developed diarrhea from the stress. She doesn't understand why she feels so anxious and is unable to attribute it to anything specific aspect of her life right now. You decide to begin pharmacotherapy. All of the following are suitable mechanisms of drugs that can treat this illness EXCEPT:?
{'A': 'A drug that stimulates 5-HT1A receptors', 'B': 'A drug that blocks 5-HT reuptake', 'C': 'A drug that blocks both serotonin and norepinephrine reuptake', 'D': 'A drug that acts as a GABA agonist', 'E': 'A drug that blocks dopamine 2 receptors'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Respiratory alkalosis | Q:A 17-year-old female is brought to the emergency room by her parents shortly after a suicide attempt by aspirin overdose. Which of the following acid/base changes will occur FIRST in this patient??
{'A': 'Non-anion gap metabolic acidosis', 'B': 'Anion gap metabolic acidosis', 'C': 'Respiratory acidosis', 'D': 'Metabolic alkalosis', 'E': 'Respiratory alkalosis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Leprosy | Q:During a humanitarian medical mission in rural Vietnam, a medical resident encounters a 50-year-old man with a year-long history of a pruritic rash on his upper body and face, along with numbness and tingling sensation of both of his palms. He mostly works on his family’s rice farm, where he also takes care of livestock. A physical examination revealed multiple erythematous macules and papules on the face, arms, chest, and back, as well as thinning of the eyebrows and loss of some eyelashes. Additional findings include hypopigmented macules around the elbows, which are insensitive to light touch, temperature, and pinprick. The grip strength is slightly diminished bilaterally with the conservation of both bicipital reflexes. What is the most likely diagnosis??
{'A': 'Cutaneous leishmaniasis', 'B': 'Sporotrichosis', 'C': 'Tinea corporis', 'D': 'Leprosy', 'E': 'Scrofula'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Bipolar I disorder | Q:A 21-year-old female is brought to the emergency department by her roommate. Her roommate says that the patient has been acting “strangely” for the past 10 days. She has noticed that the patient has been moving and talking on the phone at all hours of the night. She doesn’t think that the patient sleeps more than one to two hours a night. She also spends hours pacing up and down the apartment, talking about “trying to save the world.” She also notices that the patient has been speaking very fast. When asking the patient if anything seems different, the patient denies anything wrong, only adding that, “she’s made great progress on her plans." The patient said she has felt like this on one occasion 2 years ago, and she recalled being hospitalized for about 2 weeks. She denies any history of depression, although she said about a year ago she had no energy and had a hard time motivating herself to go to class and see her friends for months. She denies hearing any voices or any visual hallucinations. What is the most likely diagnosis in this patient??
{'A': 'Schizoaffective disorder', 'B': 'Major depressive disorder', 'C': 'Bipolar I disorder', 'D': 'Bipolar II disorder', 'E': 'Dysthymic disorder'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Blood loss | Q:An 87-year-old woman is brought to the emergency department 30 minutes after a fall onto a hardwood floor. She landed on her left side and hit the left side of her head. She did not lose consciousness. She has a mild headache over the left temple and severe left hip pain. She has had nasal congestion, a sore throat, and a productive cough for the last 2 days. She has a history of atrial fibrillation, coronary artery disease, hypertension, and osteoporosis. She underwent two coronary artery bypass grafts 5 years ago. She had smoked one pack of cigarettes daily for 30 years but quit 30 years ago. Her current medications include aspirin, apixaban, diltiazem, omeprazole, and vitamin D supplementation. The patient is oriented to person, place, and time. There is a 2-cm ecchymosis over the left temple. Examination of the left hip shows swelling and tenderness; range of motion is limited. Intravenous morphine 2 mg is started. During further examination, the patient complains of dizziness and palpitations. She is diaphoretic and pale. Her skin is cold and clammy. Her pulse is 110/min and faint, respirations are 20/min, and blood pressure is 70/30 mm Hg. Cranial nerves are intact. Cardiac examinations shows no murmurs, rubs, or gallops. An ECG shows absent P waves and nonspecific changes of the ST segment and the T wave. Which of the following is the most likely underlying mechanism for the patient's sudden decline in her condition??
{'A': 'Pulmonary embolism', 'B': 'Cardiac tamponade', 'C': 'Brain herniation', 'D': 'Sepsis', 'E': 'Blood loss'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Compression of the left renal vein at the aortic origin of the superior mesenteric artery | Q:A 27-year-old male presents with primary complaints of a palpable mass in his scrotum and mild testicular pain. Physical exam reveals an abnormal appearing scrotum around the left testis, as depicted in image A. Which of the following is the most likely etiology of this presentation??
{'A': 'Compression of the left renal vein at the aortic origin of the superior mesenteric artery', 'B': 'Patent processus vaginalis allowing fluid entry into the scrotum', 'C': 'Neisseria gonorrhoeae Infection of the left testis leading to epididymitis', 'D': 'Unilateral failure of the left testis to descend into the scrotum', 'E': 'Twisting of the spermatic cord secondary to rotation of the left testis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Forced immersion in hot water | Q:A 30-month-old boy is brought to the emergency department by his parents. He has burns over his left hand. The mother tells the doctor that the child was playing unobserved in the kitchen and accidentally grabbed a hot spoon, which produced the burn. She also says his pediatrician had expressed concern as to the possibility of autism spectrum disorder during the last visit and had suggested regular follow-up. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. On physical examination, his temperature is 37.0°C (98.6°F), pulse rate is 140/min, and respiratory rate is 28/min. He is irritable and crying excessively. On examination, the skin of the left hand is white-pink with small blisters over the entire dorsal aspect of the hand, but the skin of the palmar surface is undamaged. There is a sharp demarcation between healthy skin above the wrist and the injured skin of the hand. There are no burns or another injury anywhere else on the child. Which of the following is the most likely cause of the burns??
{'A': 'Forced immersion in hot water', 'B': 'Burn as a result of poor supervision', 'C': 'Cigarette burns', 'D': 'Accidental burns', 'E': 'Abusive burn from a hot spoon'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Decreased serum Na+ | Q:A 75-year-old man is brought to the emergency department for a 5-day-history of worsening dyspnea, orthopnea, and lower leg swelling. He has a history of hypertension, hyperlipidemia, non-alcoholic fatty liver disease, and myocardial infarction 10 years ago. Current medications include metoprolol, lisinopril, ethacrynic acid, eplerenone, and aspirin. He drinks 1 beer daily. He has a 30-pack-year smoking history. He is allergic to sulfonamides. His temperature is 37.0°C (98.6°F), his pulse is 120/min, and his blood pressure is 120/80 mm Hg. Physical examination reveals jugular venous distention and 3+ pitting edema in his lower legs. Crackles are heard at both lung bases. The point of maximal impulse is 2 cm to the left of the midclavicular line in the 6th intercostal space. Which of the following additional findings would be most strongly associated with increased mortality??
{'A': 'Decreased BNP levels', 'B': 'Decreased serum Na+', 'C': 'Decreased QRS complex duration', 'D': 'Increased VO2', 'E': 'Increased heart rate variability'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: [30 / (30 + 70)] / [1 / (1 + 99)] | Q:You have been asked to quantify the relative risk of developing bacterial meningitis following exposure to a patient with active disease. You analyze 200 patients in total, half of which are controls. In the trial arm, 30% of exposed patients ultimately contracted bacterial meningitis. In the unexposed group, only 1% contracted the disease. Which of the following is the relative risk due to disease exposure??
{'A': '[30 / (30 + 70)] / [1 / (1 + 99)]', 'B': '(30 * 99) / (70 * 1)', 'C': '[70 / (30 + 70)] / [99 / (1 + 99)]', 'D': '(70 * 1) / (39 * 99)', 'E': '[1 / (1 + 99)] / 30 / (30 + 70)]'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Bacterial superinfection of skin lesions | Q:A father brings in his 7-year-old twin sons because they have a diffuse rash. They have several papules, vesicles, pustules, and crusts on their scalps, torso, and limbs. The skin lesions are pruritic. Other than that, the boys appear to be well. The father reports that several children in school have a similar rash. The family recently returned from a beach vacation but have not traveled internationally. Both boys have stable vital signs within normal limits. What is the most common complication of the infection the boys appear to have??
{'A': 'Hepatitis', 'B': 'Bacterial superinfection of skin lesions', 'C': 'Pneumonia', 'D': 'Encephalitis', 'E': 'Cerebellar ataxia'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Loss of E-cadherin | Q:A 75-year-old female comes to the physician’s office with complaints of right lower quadrant pain. She has been experiencing these symptoms for the last 6 months and they have progressively gotten worse. An ultrasound reveals a large ovarian mass and abdominal and pelvic CT reveals no metastases. Her serum levels of CA-125 are elevated and the biopsy reveals the primary neoplasm as ovarian in origin. Her cancer is characterized as invasive carcinoma without metastasis. Which of the following cellular changes is consistent with this diagnosis??
{'A': 'Appropriate basal to apical differentiation', 'B': 'Intact basement membrane', 'C': 'Loss of E-cadherin', 'D': 'Seeding via capillaries', 'E': 'Increased proliferation of cells with preservation of size and shape'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Growth retardation | Q:A 36-year-old African American woman G1P0 at 33 weeks gestation presents to the emergency department because "her water broke." Her prenatal history is remarkable for proteinuria in the absence of hypertension during her third trimester check-up. She denies any smoking, alcohol use, sick contacts, abdominal pain, fever, nausea, vomiting, or diarrhea. Her temperature is 98.6°F (37°C), blood pressure is 150/90 mmHg, pulse is 120/min, and respirations are 26/min. While the on-call obstetrician is on her way to the emergency department, the following labs are obtained:
Hemoglobin: 11 g/dL
Hematocrit: 35 %
Leukocyte count: 9,800/mm^3 with normal differential
Platelet count: 400,000/mm^3
Serum:
Na+: 137 mEq/L
Cl-: 99 mEq/L
K+: 3.9 mEq/L
HCO3-: 22 mEq/L
BUN: 35 mg/dL
Glucose: 128 mg/dL
Creatinine: 1.2 mg/dL
Urine:
Epithelial cells: Scant
Protein: 2+
Glucose: 1+
WBC: 2/hpf
Bacterial: None
What is the most likely finding in the neonate after delivery??
{'A': 'Growth retardation', 'B': 'Meconium aspiration', 'C': 'Microcephaly', 'D': 'Seizures', 'E': 'Stillbirth'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Maternal phenytoin therapy | Q:A 30-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital in active labor. Her first pregnancy and delivery were complicated by iron deficiency anemia and pregnancy-induced hypertension. She has had no routine prenatal care during this pregnancy but was diagnosed with oligohydramnios 4 weeks ago. The remainder of her medical history is not immediately available. A 2400-g (5.4-lb) female newborn is delivered vaginally. Examination of the newborn shows a short, mildly webbed neck and low-set ears. Ocular hypertelorism along with slanted palpebral fissures are noted. A cleft palate and hypoplasia of the nails and distal phalanges are present. There is increased coarse hair on the body and face. Which of the following best explains the clinical findings found in this newborn??
{'A': 'Maternal phenytoin therapy', 'B': 'Fetal posterior urethral valves', 'C': 'Maternal diabetes mellitus', 'D': 'Maternal alcohol intake', 'E': 'Fetal X chromosome monosomy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Aldosterone | Q:A 32-year-old female presents to her obstetrician 3 weeks postpartum for failure to lactate. Of note, she has been unable to tolerate cold environments since the birth of her child. Review of systems is positive for fatigue, lightheadedness, and a 3-pound weight gain over the last 3 weeks. Her delivery was complicated by placenta accreta with postpartum blood loss. Her newborn infant is doing well on formula. She denies any personal or family history of thyroid disease. Physical exam is overall unremarkable. On a panel of hormone testing, which of the following levels is most likely to be normal in this patient??
{'A': 'Antidiuretic hormone', 'B': 'Aldosterone', 'C': 'Cortisol', 'D': 'Luteinizing hormone', 'E': 'Thyroid hormone'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Esophageal smooth muscle atrophy and fibrosis | Q:A 44-year-old woman comes to the physician because of a 2-year history of progressive dysphagia. She initially had symptoms only when consuming solid foods, but for the past 2 months she has also had difficulty swallowing liquids. She describes a feeling of food “getting stuck” in her throat. She was diagnosed with gastroesophageal reflux disease 2 years ago and has had episodic pallor of her fingers since adolescence. She has smoked half a pack of cigarettes daily for 24 years. Her only medication is omeprazole. Her pulse is 65/min, respirations are 12/min, and blood pressure is 127/73 mm Hg. Examination shows thickening of the skin of her fingers, with small white papules on her fingertips. There are small dilated blood vessels on her face, lips, and tongue. Cardiopulmonary examination shows no abnormalities. Which of the following is the most likely cause of this patient's dysphagia??
{'A': 'Uncoordinated contractions of the esophagus', 'B': 'Protrusion of thin tissue membranes into the esophagus', 'C': 'Esophageal smooth muscle atrophy and fibrosis', 'D': 'Degeneration of upper and lower motor neurons', 'E': 'Outpouching of the lower pharyngeal mucosa and submucosa\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Discontinue antibiotic | Q:A 14-year-old boy is brought to the emergency department by his parents for joint pain following the acute onset of a diffuse, pruritic rash for the past 24 hours. A week ago, he was diagnosed with pharyngitis after returning home from summer camp and is currently taking antibiotics. There is no family history of serious illness. His temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure is 110/70 mm Hg. Physical examination shows periorbital edema, generalized lymphadenopathy, and well-circumscribed, erythematous, confluent skin lesions of variable sizes up to several centimeters in width over his entire body. There is pain on passive movement of wrists and ankle joints bilaterally. Urine dipstick shows 1+ proteinuria. There is no hematuria. Which of the following is the most appropriate next step in management??
{'A': 'Switch medication to doxycycline', 'B': 'Discontinue antibiotic', 'C': 'Administer prednisone', 'D': 'Perform allergy testing', 'E': 'Administer diphenhydramine\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Levofloxacin | Q:A 61-year-old woman comes to the physician because of a 6-day history of cough, shortness of breath, and fever. She also reports that she has had 4 episodes of watery diarrhea per day for the last 3 days. She has chronic bronchitis. She has smoked one pack of cigarettes daily for the past 30 years. Her temperature is 39°C (102.2°F) and pulse is 65/min. Examination shows diffuse crackles over the left lower lung field. Laboratory studies show:
Hemoglobin 13.8 g/dL
Leukocyte count 16,000/mm3
Platelet count 150,000/mm3
Serum
Na+ 131 mEq/L
Cl- 102 mEq/L
K+ 4.7 mEq/L
An x-ray of the chest shows consolidation of the left lower lobe. A Gram stain of induced sputum shows numerous neutrophils but no organisms. Which of the following is the most appropriate pharmacotherapy?"?
{'A': 'Rifampin', 'B': 'Amoxicillin', 'C': 'Vancomycin', 'D': 'Levofloxacin', 'E': 'Cotrimoxazole'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: 25-hydroxyvitamin D | Q:A 70-year-old woman presents to the office for a yearly physical. She states she has recently started experiencing pain in her legs and her back. Last year, she experienced a fracture of her left arm while trying to lift groceries. The patient states that she does not consume any dairy and does not go outside often because of the pain in her legs and back. Of note, she takes carbamazepine for seizures. On exam, her vitals are within normal limits. You suspect the patient might have osteomalacia. Testing for which of the following is the next best step to confirm your suspicion??
{'A': '7-dehydrocholesterol', 'B': '25-hydroxyvitamin D', 'C': '1,25-hydroxyvitamin D', 'D': 'Pre-vitamin D3', 'E': 'Dietary vitamin D2'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Mitral regurgitation | Q:A 3-year-old boy is brought to the physician for evaluation of developmental delay. He could sit alone at 12 months and started walking with support at the age of 2 years. He can name only very few familiar objects and uses simple two-word sentences. He cannot stack more than 2 blocks. His parents report that he does not like playing with other children. He is at the 80th percentile for head circumference, 85th percentile for height, and 50th percentile for weight. He has a long and narrow face as well as large protruding ears. His thumbs can be passively flexed to the ipsilateral forearm. This patient is at increased risk of developing which of the following conditions??
{'A': 'Acute myeloid leukemia', 'B': 'Aortic dissection', 'C': 'Type 2 diabetes mellitus', 'D': 'Hyperuricemia', 'E': 'Mitral regurgitation'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Increase in deoxyuridine monophosphate | Q:A 25-year-old woman is brought to the emergency department because of a 1-day history of lower abdominal pain and vaginal bleeding. Her last menstrual period was 7 weeks ago. A urine pregnancy test is positive. A pelvic ultrasound shows a normal appearing uterus with an empty intrauterine cavity and a minimal amount of free pelvic fluid. Treatment with a drug is begun. Which of the following is the most likely effect of this drug??
{'A': 'Decrease in guanylate', 'B': 'Increase in thymidine monophosphate', 'C': 'Increase in deoxyuridine monophosphate', 'D': 'Decrease in phosphoribosyl pyrophosphate', 'E': 'Increase in tetrahydrofolate polyglutamate'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: No screening test is recommended | Q:A 71-year-old man presents to the physician for a routine health-maintenance examination. He feels well; however, he is concerned about the need for prostate cancer screening. He has a 3-year history of benign prostatic hyperplasia. His symptoms of urinary hesitancy and terminal dribbling of urine are well controlled with tamsulosin and finasteride. He also had a percutaneous coronary angioplasty done 2 years ago following a diagnosis of unstable angina. His medication list also includes aspirin, atorvastatin, losartan, and nitroglycerin. His vital signs are within normal limits. He has never had a serum prostate-specific antigen (PSA) test or prostate ultrasonography. Which of the following is the most appropriate screening test for prostate cancer in this patient??
{'A': 'Prostate ultrasonography every year', 'B': 'Prostate ultrasonography every 5 years', 'C': 'Serum PSA every year', 'D': 'Serum PSA every 2-4 years', 'E': 'No screening test is recommended'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Thyroid scintigraphy | Q:A 47-year-old woman presents to the clinic complaining of difficulty swallowing that started 1 month ago. The patient also reports a weight loss of 10 lbs during this time, without a change in her appetite. She denies fatigue, cough, hoarseness, pain, or hemoptysis. The patient has a history of childhood lymphoma, which was treated with radiation. She takes no medications. She has smoked 1 pack of cigarettes per day since she was 25 years old. Her physical exam is notable for a palpable nodule on the right side of the thyroid. An ultrasound is performed, which confirms a 1.2 cm hyperechoic nodule in the right lobe. Thyroid function labs are drawn and shown below:
Serum TSH: 0.2 mU/L
Serum thyroxine (T4): 187 nmol/L
Serum triiodothyronine (T3): 3.3 nmol/L
Which of the following is the next best step in management??
{'A': 'Fine needle aspiration', 'B': 'Levothyroxine', 'C': 'Partial thyroidectomy', 'D': 'Radioactive iodine', 'E': 'Thyroid scintigraphy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Subglottic larynx | Q:A 2-year-old boy is brought to the physician by his parents for the evaluation of an unusual cough, a raspy voice, and noisy breathing for the last 2 days. During this time, the symptoms have always occurred in the late evening. The parents also report that prior to the onset of these symptoms, their son had a low-grade fever and a runny nose for 2 days. He attends daycare. His immunizations are up-to-date. His temperature is 37.8°C (100°F) and respirations are 33/min. Physical examination shows supraclavicular retractions. There is a high-pitched breath sound on inspiration. Which of the following is the most likely location of the abnormality??
{'A': 'Bronchioles', 'B': 'Epiglottis', 'C': 'Supraglottic larynx', 'D': 'Subglottic larynx', 'E': 'Bronchi\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Type II hypersensitivity reaction | Q:A 9-year-old boy from Eritrea is admitted to the hospital for lethargy and increased work of breathing. He has had recurrent episodes of fever, shortness of breath, and fatigue in the past 3 years. His pulse is 132/min and blood pressure is 90/66 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Auscultation of the chest shows coarse crackles in both lungs and a diastolic murmur at the cardiac apex. Despite appropriate lifesaving measures, he dies. A photomicrograph of a section of myocardium obtained at autopsy is shown. Which of the following is the most likely underlying cause of this patient's cardiac disease??
{'A': 'Amastigote infiltration', 'B': 'Beta-myosin heavy chain defect', 'C': 'Non-caseating granulomatous inflammation', 'D': 'Type II hypersensitivity reaction', 'E': 'Exotoxin-mediated myonecrosis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Decreased serum TSH | Q:A 52-year-old woman presents to her primary care physician with symptoms of heat intolerance, unintentional weight loss, feelings of anxiety, and excessive energy that hinder her from falling asleep at night. On physical exam, the patient is found to have mildly protuberant eyes bilaterally as well as discoloration and swelling of her shins. Which of the following lab results would most likely be present in this patient??
{'A': 'Decreased anti-TSH antibodies', 'B': 'Decreased free T4', 'C': 'Decreased serum TSH', 'D': 'Increased anti-mitochondrial antibodies', 'E': 'Increased serum TSH'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Hydrocodone and indomethacin | Q:A 35-year-old man presents with acute-onset right flank pain. He says that his symptoms began suddenly 6 hours ago and have not improved. He describes the pain as severe, colicky, and ‘coming in waves’. It is localized to the right flank and radiates to the groin. He says he has associated nausea. He denies any fever, chills, dysuria, or hematuria. His past medical history is significant for asymptomatic nephrolithiasis, diagnosed 9 months ago on an upright abdominal radiograph, which has not yet been treated. The patient’s vital signs include: temperature 37.0°C (98.6°F), blood pressure 145/90 mm Hg, pulse 119/min, and respiratory rate 21/min. On physical examination, the patient is constantly moving and writhing with pain. There is severe right costovertebral angle tenderness. The remainder of the physical examination is unremarkable. A urine dipstick shows 2+ blood. A noncontrast CT of the abdomen and pelvis reveals a 4-mm-diameter radiopaque stone at the right ureteropelvic junction. Several nonobstructing small-diameter stones are noted in the left kidney. Mild hydronephrosis of the right kidney is noted. Intravenous fluids are started and ondansetron is administered. Which of the following is the next best step in the management of this patient??
{'A': 'Emergency percutaneous nephrostomy', 'B': 'Hydrocodone and indomethacin', 'C': '24-hour urine chemistry', 'D': 'Lithotripsy', 'E': 'Potassium citrate'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Evaluation of brainstem reflexes | Q:A 22-year-old man is brought to the emergency department by ambulance 1 hour after a motor vehicle accident. He did not require any circulatory resuscitation at the scene, but he was intubated because he was unresponsive. He has no history of serious illnesses. He is on mechanical ventilation with no sedation. His blood pressure is 121/62 mm Hg, the pulse is 68/min, and the temperature is 36.5°C (97.7°F). His Glasgow coma scale (GCS) is 3. Early laboratory studies show no abnormalities. A search of the state donor registry shows that he has registered as an organ donor. Which of the following is the most appropriate next step in evaluation??
{'A': 'Apnea test', 'B': 'Brain MRI', 'C': 'Cerebral angiography', 'D': 'Electroencephalography', 'E': 'Evaluation of brainstem reflexes'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Serum intact parathyroid hormone level | Q:A 72-year-old woman with a medical history significant for chronic kidney disease stage 4, hypertension, and type 2 diabetes mellitus, presents to the office for a scheduled visit. During her last visit, the physician started discussing with her the possibility of starting her on dialysis for her chronic kidney disease. The patient has no complaints about her health and enjoys spending time with her family. At presentation, she is afebrile; the blood pressure is 139/89 mm Hg and the heart rate is 80/min. On physical examination, her pulses are bounding, the complexion is pale, she has a grade ⅙ holosystolic murmur, breath sounds remain clear, and 2+ pedal edema to the knee. The measurement of which of the following laboratory values is most appropriate to screen for renal osteodystrophy in this patient??
{'A': 'Erythrocyte sedimentation rate', 'B': 'Serum C-reactive protein level', 'C': 'Serum intact parathyroid hormone level', 'D': 'Serum thyroid-stimulating hormone level', 'E': 'Serum vitamin B-12 level'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Decreased thyroid-stimulating hormone | Q:A 44-year-old woman presents to her physician’s office for weakness. She reports having some difficulty placing books on a high shelf and getting up from a seated position. She denies muscle pain or any new rashes. She has noticed a tremor that is worse with action and has been having trouble falling asleep and staying asleep. She has lost approximately 10 pounds unintentionally over the course of 2 months. Medical history is significant for type I diabetes mellitus managed with an insulin pump. Family history is notable for systemic lupus erythematosus in her mother and panic disorder in the father. Her temperature is 98.6°F (37 °C), blood pressure is 140/85 mmHg, pulse is 102/min, and respirations are 17/min. On physical exam, she is mildly diaphoretic and restless, she has notable lid retraction, and her hair is thin. She has 4/5 strength in the proximal upper and lower extremities. Biceps and patellar tendon reflexes are 3+. Which of the following laboratory findings are most likely present in this patient??
{'A': 'Anti-Mi-2 antibody positivity', 'B': 'Anti-nuclear antibody positivity', 'C': 'Decreased thyroid-stimulating hormone', 'D': 'Increased erythrocyte sedimentation rate', 'E': 'Normal laboratory results'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Esophageal tear | Q:A 23-year-old college senior visits the university health clinic after vomiting large amounts of blood. He has been vomiting for the past 36 hours after celebrating his team’s win at the national hockey championship with his varsity friends while consuming copious amounts of alcohol. His personal medical history is unremarkable. His blood pressure is 129/89 mm Hg while supine and 100/70 mm Hg while standing. His pulse is 98/min, strong and regular, with an oxygen saturation of 98%. His body temperature is 36.5°C (97.7°F), while the rest of the physical exam is normal. Which of the following is associated with this patient’s condition??
{'A': 'Portal hypertension', 'B': 'Esophageal perforation', 'C': 'Esophageal metaplasia', 'D': 'Output of the esophageal mucosa', 'E': 'Esophageal tear'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Renal ultrasound | Q:A 29-year-old G1P0 at 23 weeks of gestation presents to the ED for left flank pain migrating to the groin. The pain is sharp, causing her to have nausea and vomiting. She also endorses urinary frequency, but denies vaginal discharge. There have been no complications in her pregnancy thus far. Her abdominal exam is remarkable for left lower quadrant tenderness to palpation with pain radiating to the left groin, but no guarding. She also has tenderness to palpation of the left flank. Blood is visible on inspection of the perineal area.
Urinalysis:
Urine Color: Yellow
pH: 7.1
Specific gravity: 1.010
Blood: 3+
Bilirubin: Negative
Glucose: Negative
Ketones: Negative
Protein: Negative
Nitrite: Negative
Leukocyte esterase: Negative
Red blood cells: 291 cells/ul
White blood cells: 75 cells/ul
Which of the following is the next best step in management??
{'A': 'Renal radiograph', 'B': 'Intravenous pyelogram', 'C': 'Renal ultrasound', 'D': 'Noncontrast CT scan of abdomen and pelvis', 'E': 'Exploratory laparoscopy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Escherichia coli | Q:A 26-year-old female presents to her primary care physician concerned that she has contracted a sexually transmitted disease. She states that she is having severe pain whenever she urinates and seems to be urinating more frequently than normal. She reports that her symptoms started after she began having unprotected sexual intercourse with 1 partner earlier this week. The physician obtains a urinalysis which demonstrates the following, SG: 1.010, Leukocyte esterase: Positive, Nitrites: Positive, Protein: Trace, pH: 5.0, RBC: Negative. A urease test is performed which is negative. This patient has most likely been infected with which of the following organisms??
{'A': 'Proteus mirabilis', 'B': 'Klebsiella pneumoniae', 'C': 'Escherichia coli', 'D': 'Staphylococcus saprophyticus', 'E': 'Enterobacter cloacae'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Perform gonioscopy | Q:A 57-year-old woman comes to the emergency department because of severe pain around her right eye, blurred vision in the same eye, and a headache for the past 4 hours. She is nauseous but has not vomited. She can see colored bright circles when she looks at a light source. She is currently being treated for a urinary tract infection with trimethoprim-sulfamethoxazole. She appears uncomfortable. Vital signs are within normal limits. Examination shows visual acuity of 20/20 in the left eye and counting fingers at 5 feet in the right eye. The right eye shows conjunctival injection and edema of the cornea. The right pupil is dilated and fixed. Intravenous analgesia and antiemetics are administered. Which of the following is the most appropriate next step in management??
{'A': 'Perform ultrasound biomicroscopy', 'B': 'Administer topical atropine', 'C': 'Perform gonioscopy', 'D': 'Perform fundoscopy', 'E': 'Administer topical steroids'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Fasting blood glucose | Q:A 48-year-old Caucasian woman presents to her physician for an initial visit. She has no chronic diseases. The past medical history is significant for myomectomy performed 10 years ago for a large uterine fibroid. She had 2 uncomplicated pregnancies and 2 spontaneous vaginal deliveries. Currently, she only takes oral contraceptives. She is a former smoker with a 3-pack-year history. Her last Pap test performed 2 years ago was negative. She had a normal blood glucose measurement 3 years ago. The family history is remarkable for systolic hypertension in her mother and older brother. The blood pressure is 110/80 mm Hg, heart rate is 76/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient is afebrile. The BMI is 32 kg/m2. Her physical examination is unremarkable. Which of the following preventative tests is indicated for this patient at this time??
{'A': 'Abdominal ultrasound', 'B': 'Chest CT', 'C': 'Pap smear', 'D': 'Fasting blood glucose', 'E': 'Colonoscopy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Cephalosporin | Q:An investigator is studying a strain of bacteria that retains a blue color after crystal violet dye and acetone are applied. The bacteria are inoculated in a petri dish containing hypotonic saline. After the addition of an antibiotic, the bacteria swell and rupture. This antibiotic most likely belongs to which of the following classes??
{'A': 'Macrolide', 'B': 'Cephalosporin', 'C': 'Fluoroquinolone', 'D': 'Sulfonamide', 'E': 'Tetracycline'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Uterine fundal massage | Q:Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management??
{'A': 'Discontinuing oxytocin', 'B': 'Intramuscular carboprost', 'C': 'Intravenous methylergonovine', 'D': 'Manual exploration of the uterus', 'E': 'Uterine fundal massage'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Müllerian duct agenesis | Q:A 17-year-old girl is brought to the physician because she has not had a menstrual period. There is no personal or family history of serious illness. Examination shows normal breast development. Pubic hair is coarse and extends to the inner surface of the thighs. Pelvic examination shows a blind vaginal pouch. Ultrasonography shows ovaries, but no uterus. Which of the following is the most likely underlying cause of this patient's symptoms??
{'A': '17-alpha-hydroxylase enzyme deficiency', 'B': 'Müllerian duct agenesis', 'C': 'Androgen insensitivity', 'D': 'Pure gonadal dysgenesis', 'E': 'Failure of Müllerian duct recanalization\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Heroin | Q:A 32-year-old man comes to the emergency department because of abdominal pain, a runny nose, and chills for 6 hours. He has also had diarrhea and difficulty sleeping. He appears irritable. His temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/90 mm Hg. Examination shows cool, damp skin with piloerection. The pupils are 7 mm in diameter and equal in size. Cardiopulmonary examination shows no abnormalities. The abdomen is tender to palpation. Bowel sounds are hyperactive. Deep tendon reflexes are 3+ bilaterally. Withdrawal from which of the following substances is the most likely cause of this patient's symptoms??
{'A': 'Gamma-hydroxybutyric acid', 'B': 'Barbiturates', 'C': 'Cannabis', 'D': 'Phencyclidine', 'E': 'Heroin'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Perform a diagnostic conization | Q:A 34-year-old G3P2 undergoes colposcopy at 15 weeks gestation due to high-grade intraepithelial lesion detected on a Pap smear. She has no history of the gynecologic disease and had normal Pap smear results prior to the current pregnancy. The pelvic examination does not reveal any cervical lesions. Colposcopy shows a non-deformed cervix with a well-visualized transformation zone. Application of acetic acid reveals an area of acetowhite epithelium 2 cm in the largest diameter located at 6 o’clock with sharp irregular borders. A punch biopsy shows irregularly shaped tongues of pleomorphic squamous epithelium cells invading the stroma to a depth of 2 mm. Which of the following describes the proper management strategy for this patient??
{'A': 'Perform a diagnostic conization', 'B': 'Terminate the pregnancy and perform a radical hysterectomy', 'C': 'Observe until 34 weeks of pregnancy', 'D': 'Perform radical trachelectomy', 'E': 'Schedule a diagnostic lymphadenectomy'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Labetalol | Q:A 24-year-old G1P0 presents to her obstetrician at 26 weeks’ gestation complaining of worsening headaches and blurry vision. Her past medical history is notable for hypertension and diabetes mellitus. Her temperature is 98.6°F (37°C), blood pressure is 160/95 mmHg, pulse is 100/min, and respirations are 18/min. On physical exam, she is tender to palpation in her abdomen and has mild edema in her extremities. A urine dipstick demonstrates 3+ protein. The patient is immediately started on IV magnesium sulfate, diazepam, and a medication that affects both a- and ß-adrenergic receptors. Which of the following medications is most consistent with this mechanism of action??
{'A': 'Labetalol', 'B': 'Propranolol', 'C': 'Metoprolol', 'D': 'Esmolol', 'E': 'Pindolol'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Bone marrow examination | Q:A 24-year-old woman complains of intermittent fever and joint pain. She says that these symptoms have been present for the past month. Before that, she had no signs or symptoms and was completely healthy. She has also lost her appetite and some weight. A complete blood count (CBC) showed severe pancytopenia. What is the next best step in evaluating this patient??
{'A': 'Bone marrow examination', 'B': 'Treatment with antibiotics', 'C': 'Repeated CBCs for several weeks and reassess', 'D': 'Treatment with corticosteroids', 'E': 'Treatment for acute leukemia'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Deposition of circulating immune complexes | Q:An 8-year-old boy presents to the emergency department with puffy eyes. The patient’s parents noticed that his eyes were very puffy this morning thus prompting his presentation. They state their son has always been very healthy and other than a rash acquired from wrestling treated with a topical antibiotic has been very healthy. His temperature is 98.3°F (36.8°C), blood pressure is 125/85 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 99% on room air. Physical exam is notable for periorbital edema but is otherwise unremarkable. Urinalysis is notable for red blood cells and an amber urine sample. Which of the following is the most likely etiology of this patient’s symptoms??
{'A': 'Autoimmune type IV collagen destruction', 'B': 'Deposition of circulating immune complexes', 'C': 'IgA-mediated vasculitis', 'D': 'IgE-mediated degranulation', 'E': 'Increased glomerular permeability to protein only'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Ascending infection | Q:A 29-year-old woman, gravida 1, para 0, at 38 weeks' gestation comes to the emergency department for sudden leakage of clear fluid from her vagina. Her pregnancy has been uncomplicated. She has largely been compliant with her prenatal care but missed some appointments. She has a history of chronic hypertension. She drinks a glass of wine once per week. Current medications include labetalol, iron, and vitamin supplements. Her temperature is 37.9°C (100.2°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Examination shows a soft and nontender abdomen on palpation. Speculum examination demonstrates clear fluid in the cervical canal. The fetal heart rate is reactive at 170/min with no decelerations. Tocometry shows no contractions. The vaginal fluid demonstrates a ferning pattern when placed onto a glass slide. Which of the following is the most likely cause of this patient's condition??
{'A': 'Ascending infection', 'B': 'Sexual intercourse during third trimester', 'C': 'β-blocker use', 'D': 'Alcohol use', 'E': 'Oligohydramnios'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Defective transferrin receptor binding | Q:A previously healthy 44-year-old man comes to his physician because of frequent urination and increased thirst for several weeks. Physical examination shows darkened skin and a firm mass in the right upper quadrant. His blood glucose is 220 mg/dL. A photomicrograph of a specimen obtained on liver biopsy is shown. Which of the following best describes the pathogenesis of the disease process in this patient??
{'A': 'Upregulation of erythropoietin production', 'B': 'Absence of β-globin synthesis', 'C': 'Absence of a serine protease inhibitor', 'D': 'Defective transferrin receptor binding', 'E': 'Defective serum copper transportation'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Actinic keratosis | Q:A 65-year-old woman comes to the clinic for an annual well-check. Her past medical history includes diabetes and hypertension, which are well-controlled with metformin and losartan, respectively. The patient reports a healthy diet consisting of mainly vegetables and lean meat. She denies smoking or alcohol use. She enjoys taking walks with her husband and sunbathing. Physical examination is unremarkable expect for a rough, scaly, sand paper-like plaque on her left dorsal hand with no tenderness or pain. What is the most likely diagnosis??
{'A': 'Actinic keratosis', 'B': 'Psoriasis', 'C': 'Rosacea', 'D': 'Seborrheic keratosis', 'E': 'Sunburn'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Liver injury | Q:A 65-year-old man comes to the physician for a routine health maintenance examination. He feels well. His most recent examination 2 years ago included purified protein derivative (PPD) skin testing and showed no abnormalities. He is a retired physician and recently came back from rural China where he completed a voluntary service at a local healthcare center. A PPD skin test is performed. Three days later, an induration of 12 mm is noted. An x-ray of the chest shows no abnormalities. He is started on a drug that inhibits the synthesis of mycolic acid. This patient is at greatest risk of developing which of the following adverse effects??
{'A': 'Optic neuropathy', 'B': 'Liver injury', 'C': 'Hyperuricemia', 'D': 'Cytochrome P-450 induction', 'E': 'Nephrotoxicity'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Increase in plasma volume | Q:A 21-year-old gravida 1 presents to her physician’s office for an antepartum visit at 11 weeks gestation. She has complaints of malaise, occasional nausea, and changes in food preferences. Her vital signs include: blood pressure 100/70 mm Hg, heart rate 90/min, respiratory rate 14/min, and temperature 36.8℃ (98.2℉). Examination reveals a systolic ejection murmur along the left sternal border. There are no changes in skin color, nails, or hair growth. No neck enlargement is noted. Blood analysis shows the following:
Erythrocyte count 3.5 million/mm3
Hb 11.9 g/dL
HCT 35%
Reticulocyte count 0.2%
MCV 85 fL
Platelet count 21,0000/mm3
Leukocyte count 7800/mm3
Serum iron 17 µmol/L
Ferritin 120 µg/L
What is the most likely cause of the changes in the patient’s blood count??
{'A': 'Decreased iron transport across the intestinal wall', 'B': 'Increase in plasma volume', 'C': 'Failure of synthesis of a D-aminolevulinic acid', 'D': 'Insufficient iron intake', 'E': 'Failure of purine and thymidylate synthesis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Odds ratio | Q:The study is performed in an attempt to determine whether there is an association between maternal exposure to 2nd-hand smoke and low birth weight. A total of 1,000 women who have given birth to at least 1 child are placed into 1 of 2 groups according to the birth weight of their 1st child. Each group includes 500 women whose 1st child either weighed < 2,500 g (5.5 lb) or > 2,500 g (5.5 lb). In the 1st group, 250 subjects admitted to living with or being in close proximity to a smoker. In the 2nd group, 50 subjects admitted to living with or being in close proximity to a smoker. Which of the following is the strongest measure of association that can be calculated from this study??
{'A': 'Odds ratio', 'B': 'Relative risk', 'C': 'Rate ratio', 'D': 'Absolute risk', 'E': 'Risk difference'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Calcium gluconate | Q:A 50-year-old woman is brought to the emergency department following a motor vehicle accident. She is awake but slow to respond. Her breath smells of alcohol. The emergency medical technician reports that her blood pressure has been dropping despite intravenous fluids. Ultrasound reveals a hypoechoic rim around the spleen, suspicious for a splenic laceration. The patient is brought into the operating room for abdominal exploration and a splenic embolization is performed. Since arriving to the hospital, the patient has received 8 units of packed red blood cells and 2 units of fresh frozen plasma. She is stabilized and admitted for observation. The next morning on rounds, the patient complains of numbness and tingling of her mouth and cramping of her hands. Her temperature is 99°F (37.2°C), blood pressure is 110/69 mmHg, and pulse is 93/min. On physical examination, her abdomen is mildly tender without distention. The surgical wound is clean, dry, and intact. Jugular venous pressure is normal. Periodic spasms of the muscles of her bilateral upper and lower extremities can be seen and tapping of the facial nerve elicits twitching of he facial muscles. Which of the following is most likely to improve the patient’s symptoms??
{'A': 'Calcium gluconate', 'B': 'Dextrose', 'C': 'Lorazepam', 'D': 'Thiamine', 'E': 'Sodium bicarbonate'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Acute mesenteric ischemia | Q:A 72-year-old man presents to the ED complaining of worsening abdominal pain over the last few hours. He also reports nausea, but denies fever, vomiting, or changes in the appearance of his bowel movements. His medical history is significant for type 2 diabetes mellitus, hypertension, coronary artery disease, stroke, atrial fibrillation, and peptic ulcer disease. Due to his recurrent bleeding peptic ulcers, he does not take warfarin. His surgical history is significant for an appendectomy as a child. His medications include metformin, lisinopril, metoprolol, and omeprazole. He has a 50-pack-year history of smoking. His temperature is 37.6 C (99.7 F), blood pressure is 146/80 mm Hg, pulse is 115/min, and respiratory rate is 20/min. On physical exam, he is in acute distress due to the pain. Pulmonary auscultation reveals scattered wheezes and decreased air entry. His heart rate is irregularly irregular, with no murmurs, rubs or gallops. Abdominal exam is significant for decreased bowel sounds and diffuse tenderness. Initial laboratory evaluation is as follows:
Na 138 mEq/L, Cl 101 mEq/L, HCO3 12 mEq/L, BUN 21 mg/dL, Cr 0.9 mg/dL, glucose 190 mg/dL, amylase 240 U/L (normal < 65 U/L).
What is the most likely diagnosis in this patient??
{'A': 'Peptic ulcer perforation', 'B': 'Acute cholecystitis', 'C': 'Acute mesenteric ischemia', 'D': 'Diabetic ketoacidosis', 'E': 'Acute pancreatitis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Urethral hypermobility | Q:A 72-year-old multiparous woman comes to the physician for the evaluation of episodes of involuntary urine leakage for the past 6 months. She loses small amounts of urine without warning after laughing or sneezing. She also sometimes forgets the names of her grandchildren and friends. She is retired and lives at an assisted-living facility. She has insulin-dependent diabetes mellitus type 2. Her mother received a ventriculoperitoneal shunt around her age. She walks without any problems. Sensation to pinprick and light touch is normal. Which of the following is the primary underlying etiology for this patient's urinary incontinence??
{'A': 'Detrusor-sphincter dyssynergia', 'B': 'Urethral hypermobility', 'C': 'Decreased cerebrospinal fluid absorption', 'D': 'Impaired detrusor contractility', 'E': 'Loss of sphincter control'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Drug-induced interstitial lung disease | Q:A 45-year-old woman presents to the office complaining of fatigue and unintentional weight loss. On examination, there is a palpable firm lymph node in the cervical area. Biopsy of the lymph node reveals Hodgkin’s lymphoma. The patient agrees to start the standard chemotherapy regimen. A few months later, after the completion of 3 successful courses, the patient presents with a dry cough and progressively worsening shortness of breath. Her temperature is 37°C (98.6°F), the blood pressure is 110/70 mm Hg, the pulse is 72/min, and the respirations are 16/min. Pulse oximetry shows an O2 saturation of 94% on room air. On spirometry, the patient's FEV1/FVC ratio is normal. Chest CT reveals bilateral diffuse cystic airspaces in middle and lower lung fields. Which of the following is the most likely cause of this patient’s current symptoms??
{'A': 'Drug-induced interstitial lung disease', 'B': 'Metastatic spread to the lungs', 'C': 'Development of chronic obstructive pulmonary disease', 'D': 'Transfusion-related acute lung injury', 'E': 'Development of bacterial pneumonia due to immunocompromised state'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Thoracic aorta, right posterior intercostal artery, right bronchial artery | Q:A 47-year-old woman comes to the emergency department after coughing up 2 cups of bright red blood. A CT angiogram of the chest shows active extravasation from the right bronchial artery. A coil embolization is planned to stop the bleeding. During this procedure, a catheter is first inserted into the right femoral artery. Which of the following represents the correct subsequent order of the catheter route??
{'A': 'Thoracic aorta, brachiocephalic trunk, right subclavian artery, right internal thoracic artery, right bronchial artery', 'B': 'Thoracic aorta, right subclavian artery, right internal thoracic artery, right bronchial artery', 'C': 'Thoracic aorta, right posterior intercostal artery, right bronchial artery', 'D': 'Thoracic aorta, right superior epigastric artery, right bronchial artery', 'E': 'Thoracic aorta, left ventricle, left atrium, pulmonary artery, right bronchial artery'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Different pigmentation throughout the lesion | Q:A 53-year-old farmer presents to the clinic for evaluation of a pigmented lesion on his arm. He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size. He otherwise does not have any complaints and is generally healthy. Which of the following findings on physical exam would suggest a malignant diagnosis??
{'A': 'Different pigmentation throughout the lesion', 'B': 'Flat lesion with symmetric hyperpigmentation', 'C': 'Hyperpigmented lesion with smooth borders', 'D': 'Symmetrical ovoid lesion', 'E': 'Tenderness to palpation'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Chronic lymphocytic leukemia | Q:A 72-year-old man comes to the physician because of fatigue and a 5-kg (11-lb) weight loss over the past 6 months despite a good appetite. He takes no medications. He does not smoke or use illicit drugs. Physical examination shows hepatosplenomegaly and diffuse, nontender lymphadenopathy. Laboratory studies show a hemoglobin concentration of 11 g/dL and a leukocyte count of 16,000/mm3. A direct antiglobulin (Coombs) test is positive. A photomicrograph of a peripheral blood smear is shown. Which of the following is the most likely diagnosis??
{'A': 'Chronic myelogenous leukemia', 'B': 'Acute myelogenous leukemia', 'C': 'Follicular lymphoma', 'D': 'Chronic lymphocytic leukemia', 'E': 'Hemophagocytic lymphohistiocytosis'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Anterior movement of ventricular septum during systole | Q:A 15-year-old adolescent presents to his pediatrician with progressive easy fatigability and exercises intolerance over the last several months. The patient was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. There is no history of palpitation, dyspnea, or lower limb edema. On physical examination his vital signs are stable. On chest auscultation, a wide fixed split in the second heart sound is detected. A medium-pitched systolic ejection murmur is present which is best heard at the left middle and upper sternal border. A short mid-diastolic rumble is also audible over the lower left sternal border, which is best heard with the bell of the stethoscope. Which of the following findings is most likely to be present on this patient’s echocardiogram??
{'A': 'Decreased right ventricular end-diastolic dimension', 'B': 'Anterior movement of ventricular septum during systole', 'C': 'Goose-neck deformity of left ventricular outflow tract', 'D': 'Increased left ventricular shortening fraction', 'E': 'Displacement of tricuspid valve leaflets inferiorly into right ventricle'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Toxoid vaccine given to mother pre-natally | Q:A one-week-old boy is brought to the emergency department by his mother, who recently immigrated to the United States and does not have health insurance. He was born at home, and has not received any medical care since birth. The mother states the boy has become irritable and has been feeding poorly. In the last day, she said he seems "stiff" and is having apparent muscle spasms. On your exam, you note the findings in figure A. Which of the following interventions might have prevented this disease??
{'A': 'Conjugated polysaccharide vaccine given to infant at birth', 'B': 'Toxoid vaccine given to mother pre-natally', 'C': 'Vitamin injection given to newborn at birth', 'D': 'Improved maternal nutrition', 'E': 'Genetic counseling'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: 3' CGG 5' | Q:Given the mRNA sequence shown below, if translation were to start at the first base, what would the tRNA anticodon be for the last amino acid translated in the chain?
5'----GCACCGGCCUGACUAUAA---3'?
{'A': "3' GCG 5'", 'B': "3' CGC 5'", 'C': "3' GAU 5'", 'D': "5' CGG 3'", 'E': "3' CGG 5'"}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Wiskott-Aldrich syndrome | Q:A 7-year-old boy is brought to a new pediatrician to establish care. He presents with a history of extensive eczema, recurrent respiratory, skin, and gastrointestinal infections, and significant thrombocytopenia. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. Given this classic grouping of clinical symptoms in a patient of this age, which of the following represents the most likely underlying medical condition??
{'A': 'Wiskott-Aldrich syndrome', 'B': 'Ataxia-telangiectasia', 'C': 'Severe combined immunodeficiency syndrome', 'D': 'Chediak-Higashi syndrome', 'E': 'Hyper-IgE disease'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Glucocerebrosidase | Q:A 9-year-old boy is brought to the physician by his mother for evaluation of diffuse bone pain in his right leg. His family immigrated to the United States 6 months ago from northern Canada. He is below the 5th percentile for height and at the 10th percentile for weight. Physical examination shows tenderness to palpation of the right distal femur. There is hepatosplenomegaly. An x-ray of right femur shows generalized trabecular thinning and several osteolytic bone lesions. Laboratory studies show:
Hemoglobin 9.2 g/dL
Leukocyte count 7,600/mm3
Platelets 71,000/mm3
A bone marrow aspirate shows mononuclear cells filled with lipid that appear like wrinkled silk. Deficiency of which of the following enzymes is the most likely cause of this patient's symptoms?"?
{'A': 'Sphingomyelinase', 'B': 'α-Galactosidase A', 'C': 'Arylsulfatase A', 'D': 'Galactocerebrosidase', 'E': 'Glucocerebrosidase'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Hypotension | Q:A 55-year-old man comes to the physician because of intermittent palpitations that occur when he is stressed, exercising, or when he drinks alcohol. Physical examination shows an irregularly irregular pulse. An ECG shows irregular QRS complexes without any discrete P waves. Pharmacotherapy with carvedilol is initiated for his condition. Compared to treatment with propranolol, which of the following adverse effects is most likely??
{'A': 'Hyperkalemia', 'B': 'Hypotension', 'C': 'Bradycardia', 'D': 'Hyperglycemia', 'E': 'Bronchospasm'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Complementation | Q:When hepatitis D was injected into an immunocompromised mouse, there was no detectable hepatitis D RNA in the blood at any time point during the next several months. When co-injected with hepatitis B, hepatitis D RNA was was detected in the blood. Which of the following best describes this phenomenon??
{'A': 'Recombination', 'B': 'Reassortment', 'C': 'Complementation', 'D': 'Phenotypic mixing', 'E': 'Transduction'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Noncaseating granulomas with multinucleated giant cells | Q:A 33-year-old woman comes to the physician because of a 4-day history of fever, anterior neck pain, and throat swelling. She has no history of serious illness. Her temperature is 38.1°C (100.6°F) and pulse is 109/min. Physical examination shows diaphoresis and a fine tremor of the outstretched hands. The thyroid gland is enlarged, firm, and tender to palpation. Serum thyroid stimulating hormone level is 0.06 μU/mL and erythrocyte sedimentation rate is 65 mm/h. 123I scan shows an enlarged thyroid gland with diffusely decreased uptake. Histologic examination of a thyroid biopsy specimen is most likely to show which of the following findings??
{'A': 'Follicular epithelial cell hyperplasia', 'B': 'Undifferentiated giant cells with areas of necrosis and hemorrhage', 'C': 'Concentric intracellular lamellar calcifications', 'D': 'Lymphocytic infiltration with germinal follicle formation', 'E': 'Noncaseating granulomas with multinucleated giant cells'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Discontinue heparin and warfarin | Q: A 43-year-old woman was admitted to the hospital for anticoagulation following a pulmonary embolism. She was found to have a deep venous thrombosis on further workup after a long plane ride coming back from visiting China. She denies any personal history of blood clots in her past, but she says that her mother has also had to be treated for pulmonary embolism in the recent past. Her past medical history is significant for preeclampsia, hypertension, polycystic ovarian syndrome, and hypercholesterolemia. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and she currently denies any illicit drug use. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 111/min, and respiratory rate 23/min. On physical examination, her pulses are bounding and complexion is pale, but breath sounds remain clear. Oxygen saturation was initially 81% on room air, with a new oxygen requirement of 8 L by face mask. On day 6 of combined heparin and warfarin anticoagulation, her platelet count decreases from 182,000/mcL to 63,000/mcL. Her international normalized ratio (INR) is not yet therapeutic. What is the next best step in therapy??
{'A': 'Continue heparin and warfarin until INR is therapeutic for 24 hours', 'B': 'Discontinue heparin; continue warfarin', 'C': 'Continue heparin; discontinue warfarin', 'D': 'Discontinue heparin and warfarin', 'E': 'Continue heparin and warfarin, and administer vitamin K'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Intravenous fluids | Q:A 68-year-old woman is brought to the emergency department by ambulance after she was found down by her daughter. She lives alone in her apartment so it is unclear when she began to develop symptoms. Her medical history is significant for cardiac arrhythmias, diabetes, pericarditis, and a stroke 2 years ago. On presentation her temperature is 98.1°F (36.7°C), blood pressure is 88/51 mmHg, pulse is 137/min, and respirations are 18/min. On physical exam her skin is cold and clammy. If special tests were obtained, they would reveal dramatically decreased pulmonary capillary wedge pressure, increased systemic vascular resistance, and mildly decreased cardiac output. Which of the following treatments would most directly target the cause of this patient's low blood pressure??
{'A': 'Antibiotic administration', 'B': 'Intravenous fluids', 'C': 'Intravenous ionotropes', 'D': 'Relieve obstruction', 'E': 'Vasopressors'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: A transvaginal ultrasound would provide a better resolution of the suspected pathology, but a transabdominal ultrasound can still be used to assess this patient | Q:A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient??
{'A': 'No imaging is indicated for this patient because the diagnosis can be made on the basis of the clinical examination', 'B': 'A transvaginal ultrasound would provide a better resolution of the suspected pathology, but a transabdominal ultrasound can still be used to assess this patient', 'C': 'Increased anterior abdominal wall adiposity does not pose any problems with a full urinary bladder, so a transabdominal ultrasound will provide the same sensitivity as a transvaginal ultrasound', 'D': 'Transabdominal ultrasound would be better for this patient because it can detect small pelvic masses better than a transvaginal ultrasound', 'E': 'Pelvic MRI is warranted in this case because transvaginal ultrasound cannot be performed and transabdominal ultrasound is unlikely to provide any diagnostic information'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Pneumocystis jirovecii | Q:A 26-year-old man comes to the physician for a follow-up examination. He was diagnosed with HIV infection 2 weeks ago. His CD4+ T-lymphocyte count is 162/mm3 (N ≥ 500). An interferon-gamma release assay is negative. Prophylactic treatment against which of the following pathogens is most appropriate at this time??
{'A': 'Aspergillus fumigatus', 'B': 'Mycobacterium tuberculosis', 'C': 'Pneumocystis jirovecii', 'D': 'Toxoplasma gondii', 'E': 'Cytomegalovirus'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: In the pyloric channel within 3 cm of the pylorus | Q:A 58-year-old department store manager comes to his doctor’s office complaining that he had recently been waking up in the middle of the night with abdominal pain. This has happened several nights a week in the past month. He has also been experiencing occasional discomfort in the afternoon. The patient's appetite has suffered as a result of the pain he was experiencing. His clothes hang on him loosely. The patient does not take any prescription or over the counter medications. The remainder of the patient’s history and physical exam is completely normal. The doctor refers the patient to a gastroenterologist for a stomach acid test and an upper gastrointestinal endoscopy which revealed that this patient is a heavy acid producer and has a gastric peptic ulcer. This ulcer is most likely found in which part of the stomach??
{'A': 'In the pyloric channel within 3 cm of the pylorus', 'B': 'Along the lesser curve at the incisura angularis', 'C': 'Proximal gastroesophageal ulcer near the gastroesophageal junction', 'D': 'In the body', 'E': 'Multiple sites throughout the stomach'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Metformin | Q:An otherwise healthy 49-year-old man presents to his primary care physician for follow-up for a high HbA1C. 3 months ago, his HbA1c was 8.9% on routine screening. Today, after lifestyle modifications, it is 8.1% and his serum glucose is 270 mg/dL. Which of the following is the best initial therapy for this patient's condition??
{'A': 'Metformin', 'B': 'Metformin added to basal insulin', 'C': 'Metformin added to an insulin secretagogue', 'D': 'Metformin added to a glucagon-like peptide 1 (GLP-1) agonist', 'E': 'Metformin added to a dipeptidyl peptidase-4 (DPP-4) inhibitor'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Nuclear remnants in erythrocytes | Q:A 9-year-old boy is brought to the physician by his parents because of right-sided shoulder pain for 1 day. He has not had chills or sweating. Over the past year, he was treated twice in the emergency department for painful swelling of his hands and feet. He emigrated with his family from Kenya 2 years ago. His temperature is 37.4°C (99.3°F), pulse is 96/min, and blood pressure is 123/82 mm Hg. Physical examination shows no tenderness, erythema, or joint swelling of the shoulder. Laboratory studies show:
Hemoglobin 7 g/dL
Mean corpuscular volume 88 μm
Reticulocyte count 9%
Leukocyte count 12,000/mm3
A peripheral blood smear is most likely to show which of the following abnormalities?"?
{'A': 'Ring-shaped inclusions in erythrocytes', 'B': 'Teardrop-shaped erythrocytes', 'C': 'Nuclear remnants in erythrocytes', 'D': 'Fragmentation of erythrocytes', 'E': 'Erythrocytes with no central pallor'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Myalgia due to decreased rosuvastatin metabolism in the presence of erythromycin | Q:A 60-year-old man with a history of coronary artery disease and hyperlipidemia presents to his internist for a follow-up visit 3 weeks after visiting an urgent care center for symptoms of cough, fever, and difficulty breathing. He had been prescribed erythromycin in addition to his usual regimen of rosuvastatin and aspirin. With which potential side effect or interaction should the internist be most concerned??
{'A': 'Gastric bleeding due to decreased aspirin metabolism in the presence of erythromycin', 'B': 'Unstable angina due to decreased rosuvastatin metabolism in the presence of erythromycin', 'C': 'Myalgia due to decreased rosuvastatin metabolism in the presence of erythromycin', 'D': 'Metabolic acidosis due to decreased aspirin metabolism in the presence of erythromycin', 'E': 'Tinnitus due to decreased aspirin metabolism in the presence of erythromycin'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Normal behavior | Q:A 15-year-old girl is brought into her pediatrician's office by her mother because the mother thinks her daughter has attention issues. The mother explains that her daughter started high school four months ago and had lackluster grades in a recent progress report despite having earned consistent top marks in middle school. The mother complains that her daughter never talks to her at home anymore. The patient yells at her mother in the exam room, and the mother is escorted out of the room. The patient scoffs that her mother is so overbeaing, ruining her good days with criticism. She begins to chew gum and states that she hates hanging out with the girls on the cheerleading squad. She denies experiencing physical abuse from anyone or having a sexual partner. She has seen kids smoke marijuana underneath the football field bleachers, but does not go near them and denies smoking cigarettes. She denies any intention to harm herself or others, thinks her grades went down because her teachers are not as good as her middle school teachers, and states she thinks she learns best by watching explanations through online videos. What is the most likely diagnosis??
{'A': 'Oppositional defiant disorder', 'B': 'Normal behavior', 'C': 'Conduct disorder', 'D': 'Attention deficit hyperactivity disorder', 'E': 'Antisocial personality disorder'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| C: Lung abscess | Q:A 47-year-old alcoholic man presents to the office for a 72-hour history of intense right hemithorax pain. He also complains of fever, chills, and sweating that started 10 days ago, as well as persistent coughing with abundant malodorous sputum. Chest radiography shows a round consolidation with hydro-aerial levels in the middle third of the right hemithorax. Sputum samples for a direct exam, culture, and bradykinin (BK) are sent. What is the correct diagnosis??
{'A': 'Bronchiectasis', 'B': 'Bronchopulmonary sequestration', 'C': 'Lung abscess', 'D': 'Tuberculosis', 'E': 'Lung cancer'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| A: Defect of the septum secundum | Q:A 9-year-old boy is brought to the clinic by his parents for an annual wellness examination. He is a relatively healthy boy who was born at term via vaginal delivery. He is meeting his developmental milestones and growth curves and is up-to-date on his immunizations. The father complains that he is picky with his food and would rather eat pizza. The patient denies any trouble at school, fevers, pain, or other concerns. A physical examination demonstrates a healthy boy with a grade 3 midsystolic ejection murmur at the second intercostal space that does not disappear when he sits up. What is the most likely explanation for this patient’s findings??
{'A': 'Defect of the septum secundum', 'B': 'Failure of the septum primum to fuse with the endocardial cushions', 'C': 'Inflammation of the visceral and parietal pericardium', 'D': 'Physiologic conditions outside the heart', 'E': 'Prolonged patency of the ductus arteriosus'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Verapamil | Q:A 24-year-old woman presents to the emergency department with palpitations for the last hour. This is her 3rd emergency department visit in the last 8 weeks due to the same complaint. She denies fever, shortness of breath, nasal discharge, bowel changes, weight loss, and heat intolerance. She has asthma that is poorly controlled despite regular inhaler use. She drinks a cup of coffee each morning, and she is physically active and jogs for at least 30 minutes daily. She is in a monogamous relationship with her boyfriend and regularly uses barrier contraceptives. Her last menses was 1 week ago. Physical examination reveals: blood pressure 104/70 mm Hg, pulse 194 /min that is regular, and respiratory rate 18/min. Her ECG is shown in the image. A gentle massage over the carotid artery for 5–10 seconds did not terminate her palpitations. What is the most appropriate next step in the management of this patient??
{'A': 'Adenosine', 'B': 'Amiodarone', 'C': 'Digoxin', 'D': 'Propranolol', 'E': 'Verapamil'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Elevated fasting blood glucose | Q:One day after a 4700-g (10-lb 6-oz) male newborn is delivered to a 28-year-old primigravid woman, he has bluish discoloration of his lips and fingernails. Oxygen saturation on room air is 81%. Examination shows central cyanosis. A continuous machine-like murmur is heard over the left upper sternal border. A single S2 heart sound is present. Supplemental oxygen does not improve cyanosis. Echocardiography shows the pulmonary artery arising from the posterior left ventricle and aorta arising from the right ventricle with active blood flow between the right and left ventricles. Further evaluation of the mother is most likely to show which of the following??
{'A': 'Prenatal lithium intake', 'B': 'Elevated serum TSH', 'C': 'Prenatal phenytoin intake', 'D': 'Positive rapid plasma reagin test', 'E': 'Elevated fasting blood glucose'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Pulsus paradoxus | Q:A 16-year-old boy with a history of severe, persistent asthma presents to the emergency department with severe shortness of breath and cough. He states that he was outside playing basketball with his friends, forgot to take his inhaler, and began to have severe difficulty breathing. On exam, he is in clear respiratory distress with decreased air movement throughout all lung fields. He is immediately treated with beta-agonists which markedly improve his symptoms. Prior to treatment, which of the following was most likely observed in this patient??
{'A': 'Inspiratory stridor', 'B': 'Increased breath sounds', 'C': 'Friction rub', 'D': "Kussmaul's sign", 'E': 'Pulsus paradoxus'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| D: Cannabis use | Q:A 3670-g (8 lb 1 oz) male newborn is delivered to a 26-year-old primigravid woman. She received adequate prenatal care and labor was uncomplicated. She has chronic hepatitis B infection and gastroesophageal reflux disease. Her only medication is ranitidine. She admits to smoking cannabis and one half-pack of cigarettes daily. She drinks two beers on the weekend. The mother is apprehensive about taking care of her baby and requests for some information regarding breastfeeding. Which of the following is a contraindication to breastfeeding??
{'A': 'Ranitidine use', 'B': 'Hepatitis B infection', 'C': 'Seropositive for cytomegalovirus', 'D': 'Cannabis use', 'E': 'Smoking\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| B: Naloxone | Q:A 35-year-old male is picked up by paramedics presenting with respiratory depression, pupillary constriction, and seizures. Within a few minutes, the male dies. On autopsy, fresh tracks marks are seen on both arms. Administration of which of the following medications would have been appropriate for this patient??
{'A': 'Methadone', 'B': 'Naloxone', 'C': 'Diazepam', 'D': 'Flumazenil', 'E': 'Buproprion'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Intubation and mechanical ventilation
" | Q:A 3900-g (8.6-lb) newborn is delivered at 38 week' gestation to a 27-year-old woman, gravida 3, para 2, via spontaneous vaginal delivery. Immediately after delivery, he spontaneously cries, grimaces, and moves all four extremities. Over the next five minutes, he becomes cyanotic, dyspneic, and tachypneic. Mask ventilation with 100% oxygen is begun, but ten minutes after delivery the baby continues to appear cyanotic. His temperature is 37.2°C (99.0°F), pulse is 155/min, respirations are 65/min, and blood pressure is 90/60 mm Hg. Pulse oximetry on 100% oxygen mask ventilation shows an oxygen saturation of 83%. Breath sounds are normal on the right and absent on the left. Heart sounds are best heard in the right midclavicular line. The abdomen appears concave. An x-ray of the chest is shown below. Which of the following is the most appropriate initial step in the management of this patient??
{'A': 'Extracorporeal life support', 'B': 'Surfactant administration', 'C': 'Surgical repair', 'D': 'Chest tube placement', 'E': 'Intubation and mechanical ventilation\n"'}, |
### Instruction:
Please answer with one of the option in the bracket
### Response:
| E: Suppression | Q:A 17-year-old boy is being seen by student health for a sports physical. He denies any recent injuries. He reports that he is doing well in his classes. He fractured his left collar bone 3 years ago, which required open reduction and internal fixation. He has not had any other surgeries. He takes no medications. His father and his paternal grandfather have hypertension. When asked about his mother, the patient tears up and he quickly begins talkig about how excited he is for baseball tryouts. He has a chance this year to be in the starting lineup if, “I just stay focused.” From previous records, the patient’s mother died of ovarian cancer 6 months ago. Which of the following defense mechanisms is the patient exhibiting??
{'A': 'Denial', 'B': 'Displacement', 'C': 'Rationalization', 'D': 'Repression', 'E': 'Suppression'}, |