Search Questions

Tiles View
List View

2012 matches found 1 ...

#	Code	QID	Subspecialty	Topic	Complexity	Importance
1	IM.1	203736	A 23 year-old woman is brought to the emergency room by her mother after cutting both of her wrists with razor blades. The daughter admits that she has been admitted to the hospital numerous times for self-mutilation and that this time it was because the man she was seeing for the past two weeks ended their relationship. As an intern is closing her wound with stitches, she remarks on how skillful, attractive, and intelligent he is and how "[he is] probably the best doctor in the world." Which of the following defense mechanisms is she likely using?	Psychiatry	Personality Disorders	L 1	A
2	IM.40	205710	An 18-year-old female is brought to a psychiatrist by her parents, who complain that the she has not left the house except for school in several weeks. The psychiatrist writes in a note that the patient has schizoid personality disorder. Which of the following is characteristic of schizoid personality disorder?	Psychiatry	Personality Disorders	L 1	A
3	IM.16	203307	A 37-year-old male with a history of asthma and peptic ulcer disease presents to the emergency department with severe abdominal pain. He states the pain began suddenly this morning, is located in his upper abdomen, and is 10/10 in severity. On exam, his vitals are T: 38.3 deg C, HR: 100 bpm, BP: 118/90, RR: 10, SaO2: 100%. Guarding and rebound tenderness are observed on abdominal exam. An EKG is obtained as shown in Figure A and amylase/lipase levels are found to be 50/20, respectively. A chest radiograph is obtained as shown in Figure B. What is the most appropriate next step in management?	Gastroenterology	Peptic Ulcer Disease	L 1	A
4	IM.3	202619	A 40-year-old man presents to the emergency department with altered mental status. He has a history of cirrhosis of the liver secondary to alcoholism. Laboratory studies show Na 140, K 2.9, Cl 100, HCO3 36, BUN 27, Cr 1.0. His home medications are lactulose and furosemide. Physical exam reveals shifting dullness consistent with ascites. Which of the following is the most appropriate treatment for this patient?	Gastroenterology	Hepatic Encephalopathy	L 1	A
5	IM.204	206231	A 21-year-old female college student presents with headache, malaise, and fever of 3 hours duration. Past medical history is unremarkable and the patient does not take medications. She denies recent alcohol or drug use. Temperature is 39°C, blood pressure is 110/70 mmHg, pulse is 76/min and respirations are 17/min. Physical examination is notable for a petechial rash present in the lower extremities bilaterally. Extension of the knee when both the hip and thigh are flexed produces pain. Which of the following is the most appropriate next step in management?	Neurologic Sciences	Meningitis	L 1	A
6	IM.75	204081	A 69-year-old man presents to the general medical clinic with palpitations. He has a history of an endocrine disorder that he reports has caused him to have chronic diarrhea and weight loss. His vital signs are temperature 37 degrees Celsius, blood pressure 130/85, heart rate 141, and respiratory rate of 18 with an oxygen saturation of 99% on room air. His pulse is irregular on physical examination. He is mentating normally and is in no acute distress. His exam is also notable for hyperreflexia and enlargement around his neck. An EKG reveals the following in figure A. What would be the next best step in management of this patient's chief complaint?	Endocrinology	Graves Disease	L 1	A
7	IM.4662	207050	A 21-year-old Cambodian patient with a history of rheumatic heart disease presents to his primary care physician for a routine check-up. He reports being compliant with monthly penicillin G injections since being diagnosed with rheumatic fever at age 15. He denies any major side effects from the treatment, except for the inconvenience of organizing transportation to a physician's office every month. On exam, the patient is found to have a loud first heart sound and a mid-diastolic rumble that is best heard at the apex. Which of the following is the next best step?	Cardiovascular	Rheumatic Heart Disease	L 1	A
8	IM.36	204042	A 15-year-old girl presents with four days of malaise, painful joints, nodular swelling over her elbows, low-grade fever, and a rash on her chest and left shoulder. Two weeks ago, she complained of a sore throat that gradually improved but was not worked up. She was seen for a follow-up approximately one week later. At this visit her cardiac exam was notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. Which of the following is the best step in the management of this patient?	Cardiovascular	Rheumatic Heart Disease	L 1	A
9	IM.75	206824	Patient A and patient B present simultaneously to the emergency department with the same cardiac valvular pathology. Both patients are observed on physical exam to have a holosystolic murmur which radiates to the axilla and is worsened by the handgrip maneuver. Patient A is in severe distress, complains of acute onset of severe shortness of breath, and has the findings observed in Figure A. A chest radiograph and EKG obtained and demonstrated by Figures B and C, respectively. Meanwhile, patient B is relatively stable and complaining only of minor palpitations. A chest radiograph and EKG are obtained and demonstrated by Figures D and E, respectively. Differences in which of the following best explains the difference presentations despite the same underlying valvular pathology in these patients?	Cardiovascular	Valvular Diseases	L 1	A
10	IM.4694	207880	A 33-year-old man is brought into the emergency department with fever, lethargy, and confusion. He is a cachectic man in acute distress, unable to respond to questions or follow commands. His friend confides that the patient has been sexually active with multiple male partners and was diagnosed with HIV several months ago, but was lost to follow up. Based on prior records, his most recent CD4 count was 65 cells/uL. Which of the following is the most appropriate next step in management?	Infectious Dis.	Human Immunodeficiency Virus (HIV)	L 1	A
11	IM.126	205796	A 24-year-old female is referred to a psychiatrist by her employer, who notes that she has had trouble finishing projects in a timely manner. After a lengthy interview, the psychiatrist writes that he believes the patient has obsessive-compulsive personality disorder. Which of the following is characteristic of obsessive-compulsive personality disorder?	Psychiatry	Personality Disorders	L 1	A
12	IM.39	205709	A 20-year-old male college student volunteers to be interviewed by a psychiatrist for a university research project. Following an extensive history, the psychiatrist writes in a note that the patient suffers from dependent personality disorder. Which of the following is characteristic of dependent personality disorder?	Psychiatry	Personality Disorders	L 1	A
13	IM.41	205711	A 40-year-old man presents for psychological evaluation prior to beginning work at a government facility that handles encrypted data. Following an extensive history, the psychiatrist writes in a note that the man likely suffers from avoidant personality disorder. Which of the following is characteristic of avoidant personality disorder?	Psychiatry	Personality Disorders	L 1	A
14	IM.43	204254	A 72-year-old woman presents to her primary care doctor for a check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her physician notes an apical, rumbling diastolic murmur that occurs following an opening snap. The rumbling is loudest at the start of diastole. She has no other physical exam findings and has no other past medical history. What is the best course of action?	Cardiovascular	Valvular Diseases	L 1	A
15	IM.61	206399	A 53-year-old man from Guatemala presents with a 6-month history of progressively worsening dyspnea on exertion and cough, which has led to marked limitation of his physical activity. As a child, he had a febrile illness characterized by arthritis affecting multiple joints and abnormal movements. On cardiac exam, he has a low-pitched diastolic rumble that is most prominent at the apex. Subsequent workup with echocardiogram confirms the diagnosis of a valvular abnormality. What is the best treatment option?	Cardiovascular	Valvular Diseases	L 1	A
16	IM.44	204050	A 32-year-old male presents presents for a new patient visit. He states that he is in good health but has had decreasing exercise tolerance and increased levels of shortness of breath over the past 5 years. He believed that it was due to aging; he has not seen a doctor in 10 years. On auscultation, you note an early diastolic decrescendo blowing murmur that radiates along the left sternal border. In the United States, what is the most likely cause of this patient's condition?	Cardiovascular	Valvular Diseases	L 1	A
17	IM.4690	207593	A 45-year-old woman from Mexico comes to your office due to recent shortness of breath. The patient states that she has recently started having trouble breathing when she is working out, but this resolves when she rests for a while. She states that she has no history of diabetes, heart disease, or hypertension, but does state that she had several colds when she was growing up that weren't treated with antibiotics. Furthermore, she has arthritis in one of her knees and both wrists. On exam, her vitals are normal, but there is a mid-diastolic rumble present at the apex. What is the best definitive treatment for this patient?	Cardiovascular	Valvular Diseases	L 1	A
18	IM.200	204206	A 66-year-old male presents to his primary care physician to discuss his increasing shortness of breathover the last 3 months. He notes that this is particularly obvious when he is mowing his lawn or climbing the stairs in his home. His past medical history is significant for hypertension that is well-controlled with lisinopril. His vital signs are as follows: T 37.6 C, HR 88, BP 136/58, RR 18, SpO2 97% RA. Physical examination is significant for an early diastolic blowing, decrescendo murmur heard best at the left sternal border, a midsystolic murmur heard best at the right upper sternal border, and a late diastolic rumbling murmur heard best at the apex on auscultation. In addition, an S3 heart sound is also present. Bounding pulses are palpated at the radial arteries bilaterally. Which of the following diagnoses is most likely in this patient?	Cardiovascular	Valvular Diseases	L 1	A
19	IM.17	202646	A 42-year-old woman presents to the emergency department with severe abdominal pain. Which of the following diagnoses, if confirmed, necessitates emergency laparotomy?	Gastroenterology	Bowel Perforation	L 1	A
20	IM.16	202645	A 60-year-old man with a history of chronic back pain poorly controlled by high-dose over-the-counter pain reliever use presents to the emergency department with abdominal pain of 2 hours duration. On physical exam, he is febrile and tachycardic and lying still on his back moaning in pain. He refuses to let you palpate his abdomen. Which of the following would you be most likely to observe on abdominal radiograph?	Gastroenterology	Bowel Perforation	L 1	A
21	IM.68	203009	A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?	Gastroenterology	Peptic Ulcer Disease	L 1	A
22	IM.11	204553	A 50-year-old man with a past medical history of parathyroid neoplasia and a pituitary tumor status post trans-sphenoidal resection presents with gnawing epigastric pain. He reports that the pain is persistent. He has been in so much pain that he has been unable to eat and has had 15 pounds of weight loss over the past month. Vital signs are stale. Physical examination is notable for tenderness on palpation of the epigastric region. Upon further diagnostic testing, which of the following might be expected?	Gastroenterology	Zollinger-Ellison Syndrome	L 1	A
23	IM.93	204540	A 75-year-old female with a long history of debilitating osteoarthritis presents to clinic complaining of gnawing abdominal pain. She has been unable to eat anything substantial for days, as food seems to aggravate the pain. Review of systems is positive for darker stools. Vital signs are stable. Abdominal exam is notable for tenderness to palpation along and just below the epigastrium, without rebound or guarding. What is the most likely diagnosis?	Gastroenterology	Peptic Ulcer Disease	L 1	A
24	IM.81	204623	A 48-year-old gentleman presents to his primary care physician complaining of epigastric pain and excessive belching. He states that he has recently been having black, tarry stools. An upper endoscopy is performed and reveals a gastric ulcer. How would food most likely affect this patient?	Gastroenterology	Peptic Ulcer Disease	L 1	A
25	IM.201	204207	A 64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasalar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI holosystolic murmur at the apex that radiates to the axilla. Which of the following valvular abnormalities would you most likely find on emergent bedside echocardiogram?	Cardiovascular	Valvular Diseases	L 1	A
26	IM.4693	207678	A 40-year-old obese man with a history of diabetes and chronic kidney disease presents with one day of excruciating pain, swelling, and redness in his greater toe. He denies any inciting trauma or similar prior episodes. Vital signs are stable. On examination, the right first toe is grossly erythematous and edematous, with range of motion limited due to pain. Deposition of which of the following is associated with the most likely underlying joint disorder?	Rheumatology	Gout	L 1	A
27	IM.166	205564	A one-day-old cyanotic infant with a grade 4/6 systolic murmur heard at the left, lower sternal border (LLSB) has the EKG shown. What is the most likely diagnosis?	Pediatrics	Congenital Heart Disease	L 1	A
28	IM.25	204816	A 42-year-old female with a history of obesity, diabetes, asthma, and hypertension presents to her primary care physician for a follow-up visit after being seen in the ED 1 week ago. She had presented to the ED with urinary urgency, dysuria, increased frequency and was diagnosed with a urinary tract infection, and ultimately discharged on appropriate antibiotic therapy. During her ED workup, an abdominal ultrasound was obtained which is demonstrated in Figure A. She currently denies a history of abdominal pain, nausea and vomiting, early satiety or any other abdominal complaints. She states that apart from her urinary tract infection, which has now successfully been resolved, she feels well. What is the appropriate management for the incidental findings observed in Figure A?	Gastroenterology	Cholelithiasis and Biliary Colic	L 1	A
29	IM.41	204832	A 42-year-old woman presents to the emergency department with severe abdominal pain. She states the pain is 9/10 in severity, is sharp in quality, located primarily on her right side, and seems to radiate to her right shoulder blade. She states that she has had similar pain in the past and it always seems to be caused by ingestion of a large meal. On exam, the patient is well appearing and her vitals are shown as: T: 36 deg C, HR: 78 bpm, BP: 130/80 mmHg, RR: 10, SaO2: 100%. A CBC, BMP, and liver function tests are ordered, and all are within normal limits. The emergency physician performs an emergency medicine bedside ultrasound (EMBU) and observes the findings shown in Figure A. What is the cause of this patient's pain?	Gastroenterology	Cholelithiasis and Biliary Colic	L 1	A
30	IM.4694	207861	A 50-year-old female comes into your office with concerns of falling. She states that over the last few months, she has a feeling of numbness and "tingling" in her feet. She denies any problems with her balance and denies vertigo, but does not feel "sure-footed." She denies any neurological history. Past medical history is significant for hysterectomy 10 years ago for menorrhagia and a bowel resection for Crohn's disease. On exam, the patient has decreased reflexes and sensation bilaterally in her lower extremities. CBC shows a Hgb of 9.1 with an MCV of 105. The peripheral blood smear is shown in Figure A. The patient's methylmalonic acid (MMA) level is elevated. What is the most likely cause?	General	Vitamin B12 (Cobalamin)	L 1	A
31	IM.38	205708	A 45-year-old male agrees to take part in a psychiatric research study of financial executives. The patient is the head of commodities trading at an international investment firm. The aim of the study is to track the incidence of narcissistic personality disorder among participants. Which of the following is characteristic of narcissistic personality disorder?	Psychiatry	Personality Disorders	L 1	A
32	IM.10	205827	A 52-year-old male is referred to psychiatry by his PCP after 3 weeks of erratic behavior. The patient has been driving to a casino 60 miles away after work every night to gamble and returning directly to work the following morning. He stresses, however, that "it isn't a problem" because he is still "full of energy" during the day at his banking job, which he "could do in [his] sleep anyway." He has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient's medical history is significant for diabetes, hypertension, hepatitis C, stage II chronic kidney disease, and congenital long QT syndrome. The patient's toxicology screen is negative for illicit drugs in the PCP's office. EKG is shown below (Figure A). Which of the following of the patient's medical conditions is a contraindication for lithium therapy?	Psychiatry	Bipolar Disorder	L 1	A
33	IM.2	203737	A 23 year-old woman is brought to the emergency room by her mother after she is found to have cut both of her wrists with razor blades. The patient admits a history of self-mutilation and attributed this incident to a recent breakup with a man she had been seeing for the previous two weeks. On morning rounds the patient reports to the team that "the nurses here are the worst I've ever seen, but all the doctors are absolute geniuses." After her immediate injuries are addressed, which of the following should be used as a first-line therapy for the patient's psychiatric condition?	Psychiatry	Personality Disorders	L 1	A
34	IM.10	205680	A prison guard working at a state penitentiary has a new 24-year-old male inmate come to the cell block that he patrols. This new inmate has a psychiatric diagnosis of antisocial personality disorder. What types of behavior (past or present) can the prison guard expect from this inmate?	Psychiatry	Personality Disorders	L 1	A
35	IM.37	205707	A 22-year-old male is brought to a psychiatrist by his mother, who claims that he has refused to bathe for two weeks and has not shaven for several months. The patient states that he refrains from grooming because he is sure such practices will help him win the lottery. This behavior is most typical of which of the following personality disorders?	Psychiatry	Personality Disorders	L 1	A
36	IM.34	202975	A 53-year-old man with type 2 diabetes mellitus presents to the emergency department complaining of the worst pain he has ever experienced in his right leg. He states that two days ago he cut his calf while working on the lawn. This morning he noticed a slight discoloration of his right calf. He says that although his leg does not look that bad, the pain is excruciating. Vital signs are as follows: T 102.5 F, HR 102 bpm, and BP 124/82. Physical exam reveals a slightly erythematous and swollen distal right calf that is extremely tender to palpation. A photo of the leg is shown in Figure A. What is the most common causative agent for this condition?	Dermatology	Necrotizing Fasciitis	L 1	A
37	IM.69	203360	A 32-year-old man presents to the emergency department complaining of excruciating pain of his left calf. He states that he was bitten by a spider three days ago; however, yesterday his calf became swollen, red, and extremely painful. His vital signs are: T 102.8 F, HR 112 bpm, and BP 134/76. On exam, his distal left leg is swollen, extremely tender to palpation, and appears purples and dusky. You note crepitus is present. A biopsy is performed and the results are shown in Figure A. What is the most likely diagnosis?	Dermatology	Necrotizing Fasciitis	L 1	A
38	IM.8	203299	A 9-year-old is brought to his outpatient pediatrician after having been hospitalized for an asthma exacerbation. As part of his follow-up, a thorough symptom history is taken and pulmonary function tests (PFTs) are conducted in the office. He says that he has some symptoms of wheezing and shortness of breath on a daily basis, particularly during exercise. He also wakes up in the middle of the night with symptoms about twice per week. This most recent hospitalization is for his second exacerbation in the last 8 months. He is on a daily controller medication (fluticasone propionate), but he uses his albuterol inhaler daily for symptom control. His PFTs show an FEV1 of 65% predicated and an FEV1/FVC of of 80%. What category best describes his asthma?	Pulmonary	Asthma	L 1	A
39	IM.18	205835	A 26-year-old female with AIDS (CD4 count: 47) presents to the emergency department in severe pain. She states that over the past week she has been fatigued and has had a progressively worse headache and fever. These symptoms have failed to remit leading her to seek care in the ED. A lumbar puncture is performed which demonstrates an opening pressure of 285 mm H2O, increased lymphocytes, elevated protein, and decreased glucose. The emergency physician subsequently initiates treatment with IV amphotericin B and PO flucytosine. What additional treatment in the acute setting may be warranted in this patient?	Infectious Dis.	Opportunistic Mycoses	L 1	A
40	IM.29	205699	A 23-year-old female presents to the emergency department with monocular blindness. She states that early this morning she lost her vision seemingly "out of nowhere." She denies trauma or any precipitating factors. She does state though that over the past year she has had occasional episodes of weakness and even an episode of urinary incontinence, which always resolve on their own. On exam, pain is elicited with eye movement and nystagmus is appreciated. The emergency physician performs a lumbar puncture. What is most likely to be observed in the CSF of this patient?	Neurologic Sciences	Multiple Sclerosis	L 1	A
41	IM.40	206113	A 26-year-old Caucasian female presents to her primary care physician because she is concerned about recent changes to her health. She states that for the past year she has had recurrent episodes of vision problems. She states that seemingly "out of the blue" her vision will become very poor and she will have pain whenever she moves her eyes. These episodes tend to last for a short time and then spontaneously resolve on their own. Upon questioning, the physician learns that she has also had periodic episodes of balance and speech difficulties which seem to self resolve in a similar fashion to her eye complaints. The physician orders an MRI which is demonstrated in Figure A. What is the appropriate treatment the next time this patient experiences an acute episode of these neurologic symptoms?	Neurologic Sciences	Multiple Sclerosis	L 1	A
42	IM.73	206591	A 47-year-old female presents to the emergency department in distress with a wound on her right lower leg. The patient describes intense pain over the site yesterday that has since dissipated; she is now insensate and not in pain. She also states that the area has been changing colors from first red to now purple/black. She reports having been stung by a bee near that spot 2 days ago. Her medical history is significant for type II diabetes, which is controlled with glipizide, and chronic headaches, for which she regularly takes naproxen. Her vital signs are as follows: T 38.9 C, HR 109, BP 80/57, RR 22, and SpO2 96%. Physical examination shows a 5cm x 12cm wound over the anterior right lower leg that is discolored purple and black towards the center of the wound with expanding edema and erythema towards the edges (Figure A). The area is insensate to light touch and pin-prick. No crepitus is noted on palpation of the wound. Which of the following is the most likely causative organism in this patient's presentation?	Dermatology	Necrotizing Fasciitis	L 1	A
43	IM.33	204824	A 52-year-old male with a history of chronic hepatitis C presents to the emergency department with his wife. His wife states that she is very concerned because she thinks that he "isn't thinking straight." She states that he awoke this morning and did not appear to know where he was. She also states that over the past 2 days he developed a productive cough and fever. On exam, the patient appears altered and his vitals are shown as Temp: 38 deg C, HR: 77 bpm, BP: 134/98 mmHg, RR: 12, SaO2: 97%. The physician observes the findings shown in Figure A and Figure B. Furthermore, when the patient holds his hands as demonstrated in Figure C, they oscillate as though he is slapping the air. A chest radiograph is obtained, which is demonstrated in Figure D. In addition to appropriate antibiotic therapy, what other medication should be initiated in this patient?	Gastroenterology	Hepatic Encephalopathy	L 1	A
44	IM.60	203550	A 22-year-old male college student is brought to the emergency department with fever and headache and is accompanied by his girlfriend. Lumbar puncture is performed and the Gram stain is shown in Figure A. Appropriate treatment is initiated and the patient is hospitalized. His girlfriend reports that they spend all their time together and also have been intimate the past several days. She is currently asymptomatic. What is the most appropriate treatment for the girlfriend?	Neurologic Sciences	Meningitis	L 1	A
45	IM.71	203012	A 30-year-old avid hiker from Massachusetts presents to your office for a 4 day history of left knee swelling and mild pain. On questioning, she vaguely recalls a rash several months ago, but states it resolved on its own after several weeks. The patient denies fever, chills, recent trauma, changes in vision, and reports only 1 sexual partner in the past 4 years. Vital signs are T 37 C, BP 110/70, P 75, RR 12. On exam, the left knee is warm to the touch and an effusion is present. No target-like lesions on her skin are noted. Besides arthrocentesis and synovial fluid analysis, which of the following is most helpful for diagnosis of this patient?	Infectious Dis.	Lyme Disease	L 1	A
46	IM.58	202687	An 18-year-old female college student is brought to the emergency department by ambulance for headache and altered mental status. The patient is accompanied by her boyfriend, who lives with her, and states she had not been feeling well for the past day. He states she has vomited several times in the past 12 hours. Lumbar puncture is performed in the emergency room, and the patient is admitted with contact precautions. Microorganisms are seen on Gram stain (Figure A), and appropriate treatment is initiated. Who of the following requires antibiotic prophylaxis?	Neurologic Sciences	Meningitis	L 1	A
47	IM.36	202977	A 40-year-old woman with a history of alcoholism presents to the emergency department complaining of extreme pain in her left leg for the past four days after falling while drunk. Vital signs are T 103.1 F, HR 115 bpm, and BP 108/74. An image of the leg is shown in Figure A. Apart from the findings on Figure A, exam is positive for severe tenderness of the left thigh and crepitus. Apart from IV fluids, what other treatment should this patient receive?	Dermatology	Necrotizing Fasciitis	L 1	A
48	IM.27	205697	A 29-year-old man presents to clinic for a general health exam. He is accompanied by his girlfriend. In the office, he seems to be running from topic to topic without a clear message. His speech is pressured. The patient's girlfriend reports that he took steroids recently for a bad sinus infection and since he started them, his behavior has been abnormal. After discontinuing the medication, he has still been having symptoms. He has not had a normal night of sleep for the past ten days, and he just bought a new sports car though he has no need for one or the money to afford it. She also reports that she has caught him with multiple other women in the past few days, though they were in a committed relationship. The physical exam is benign and the patient's vital signs are within normal limits. Regarding this patient, which of the following is true?	Psychiatry	Bipolar Disorder	L 1	A
49	IM.42	205712	A 27-year-old female presents to general obstetrics clinic for follow-up. She is in her first trimester and thus far there have been no complications. She has a history of bipolar disorder and asks about the chances that her child will also have bipolar disorder. You respond that the risk of bipolar disorder in a patient with a first degree relative is about 5-10% in comparison to the general risk of 1%. The patient reports that while you advised her to discuss temporarily discontinuing her lithium during her pregnancy with her psychiatrist, she has not taken your advice and has continued the medication. You inform her that should she continue lithium during her pregnancy, her child would also be at a risk of:	Psychiatry	Lithium	L 1	A
50	IM.98	204423	A 32-year-old woman with Graves' disease is undergoing treatment with radioactive iodine. Her initial presentation consisted of symptoms of sweating, weight-loss, and intermittent palpitations along with a physical examination significant for mild-to-moderate exophthalmos. After completing one week of radioactive iodine therapy, she reports worsening of her proptosis, with increased pain and worsened periorbital edema. Which of the following could have prevented the worsening of this patient's exophthalmos?	Endocrinology	Graves Disease	L 1	A
51	IM.211	206194	A 79-year-old female presents to her primary care physician complaining of shortness of breath. She reports that activities of daily living, such as cooking or doing laundry, make her short of breath, tired, and sometimes dizzy. Her last visit to a doctor was several years ago. Physical examination is notable for crackles at both lung bases and a crescendo-decrescendo systolic murmur heard best at the right-upper sternal border. Which of the following is the most appropriate long-term treatment option for this patient?	Cardiovascular	Aortic Stenosis	L 1	A
52	IM.4423	206987	A 34-year-old woman presents to her primary care physician with insomnia. She notes that she has had difficulty calming down for the past several months. She also reports feeling warm, even when others feel cold, and that her eyes appear to bulge more than she remembered (Figure A). Her TSH is found to be 0.03 mcU/mL (nl 0.4-2.5 mcU/mL), and free T4 is 5 ng/dl (nl 0.7-1.9 ng/dl). She chooses to undergo radioiodine ablation, and returns to her physician 2 days after the procedure noting increased bulging of her eyes. Which of the following steps could have decreased the risk of this complication?	Endocrinology	Graves Disease	L 1	A
53	IM.210	206193	A 72-year-old female presents to the emergency department following a syncopal episode while walking down several flights of stairs. The patient has not seen a doctor in several years and does not take any medications. Your work-up demonstrates that she has symptoms of angina and congestive heart failure. Temperature is 36.8 degrees Celsius, blood pressure is 160/80 mmHg, heart rate is 81/min, and respiratory rate is 20/min. Physical examination is notable for a 3/6 crescendo-decrescendo systolic murmur present at the right upper sternal border with radiation to the carotid arteries. Random blood glucose is 205 mg/dL. Which of the following portends the worst prognosis in this patient?	Cardiovascular	Aortic Stenosis	L 1	A
54	IM.4694	207868	A 40-year-old woman with a past medical history significant for pernicious anemia and vitiligo presents to the physician with the chief complaints of heat intolerance and frequent palpitations. The patient does not take birth control and her urine pregnancy test is negative today. Physical exam reveals a patient that is hyper-reflexive with a non-tender symmetrically enlarged thyroid gland. You order thyroid function tests for workup. What thyroid function values are most expected?	Endocrinology	Graves Disease	L 1	A
55	IM.4	204010	A 68-year-old male presents to his primary care physician for a routine health maintenance examination. Past medical history is unremarkable and the patient does not take any medications. Physical exam demonstrates a crescendo-decrescendo systolic ejection murmur at the right second intercostal space that radiates to the carotids. The patient does not complain of chest pain or difficulty breathing. EKG is suggestive of LV hypertrophy. The patient is followed with serial echocardiography. Three years later, the patient comes back to the physician's office complaining of chest pain with exertion. What is the most appropriate management of the patient at this time?	Cardiovascular	Aortic Stenosis	L 1	A
56	IM.29	204571	A 26-year-old male is brought to the emergency department by paramedics following a high-speed accident while riding his motorcycle. On arrival to the emergency department, he has a GCS of 6 and his vitals demonstrate T: 36 deg C, HR: 130 bpm, BP: 83/45 mmHg, RR: 8, SaO2: 96%. He is immediately intubated by the emergency room physician. A FAST ultrasound examination is performed, which is demonstrated in Figure A. Abdominal and head CT scans (Figures B and C) are obtained, and the patient is immediately brought to the operating room for surgical management. Following surgery, the patient is brought to the surgical intensive care unit (SICU) and remains comatose. The patient has a prolonged course in the SICU and total parenteral nutrition (TPN) is ultimately initiated to provide adequate nutrition. Prolonged use of TPN would predispose this patient to which of the following?	Gastroenterology	Cholelithiasis and Biliary Colic	L 1	A
57	IM.61	206406	A 69-year-old man with a history of alcoholism presents to the emergency room with abdominal pain and altered mental status. He still drinks and is a Child-Pugh Class B cirrhotic. He is accompanied by his wife, who states that he was acting normally this morning but became confused as the day progressed. His vital signs are heart rate 95 beats per minute, respiratory rate 14 breaths per minute, blood pressure 130/85 mmHg, and temperature 38.1 degrees Celsius. On physical exam, he is alert and oriented to person only. He groans when you press on his abdomen, and he has shifting dullness. What is the next best step in management?	Gastroenterology	Spontaneous Bacterial Peritonitis (SBP)	L 1	A
58	IM.14	205831	A 55-year-old woman presents to the emergency department with recent onset confusion and photophobia. Upon questioning her husband, you discover the patient has been sick over the past week with fevers and productive sputum. Her vital signs are Temperature 102.6 Pulse 80 Respirations 18 Blood Pressure 110/70. The physical exam is significant for lethargy and nuchal rigidity. A lumbar puncture is performed and demonstrates cloudy fluid with an opening pressure of 35 cm H20, cell count of 1500 cells/uL (neutrophil predominant), protein level of 50 mg/dL and glucose of 30 mg/dL. Computed tomography scan demonstrates no space-occupying lesions. What is the most appropriate initial treatment for this patient?	Neurologic Sciences	Meningitis	L 1	A
59	IM.7	205405	A four-year-old boy is brought to a general pediatrics clinic by his concerned mother who states that he intermittently turns blue. She reports that he has been growing and developing normally, but recently he has been having crying fits where he turns blue and then squats down into a ball. Vital signs are stable. Physical examination reveals a pansystolic murmur at the left lower sternal border. Which of the following is true regarding the disease affecting this patient?	Pediatrics	Congenital Heart Disease	L 1	A
60	IM.13	204804	A 55-year-old former longtime alcoholic presents to clinic complaining of new onset increasing abdominal girth and no other complaints. He had been a Child's Class A cirrhotic for some time. His wife, who has accompanied him on this visit, reports that his mental status is unchanged and that he is eating well and attending his Alcoholics Anonymous meetings. On physical exam, his vital signs are stable. His abdomen is distended and tense without appreciable hepatomegaly. There is a fluid wave and shifting dullness. You conduct abdominal paracentesis in the office and aspirate 3L of clear fluid. If sodium and water restriction fails to control this patient's symptoms, what would be the next step in management?	Gastroenterology	Ascites	L 1	A
61	IM.13	206086	A 75-year-old male presents with a 1-month history of severe abdominal and epigastric pain. He states that his pain improves with meals but worsens approximately one hour after eating. He has a history of osteoarthritis, which he treats with NSAIDs; he has increased his dose for the past 3 months due to increased pain. Vital signs are stable and within normal limits. Endoscopy is performed, and the results are shown in Figure A. What is the most common complication of this patient's condition?	Gastroenterology	Peptic Ulcer Disease	L 1	A
62	IM.12	205829	A 66-year-old male presents to the emergency department with complaints of fevers, altered mental status, neck stiffness and headaches over the past 2 days. Vital signs are as follows: T 39.2, HR 101, BP 144/88, RR 18, O2 Sat 97% RA. Physical exam is significant for involuntary flexion of the bilateral hips and knees in response to passive neck flexion. He reports being treated with antibiotics for sinusitis 8 days ago. Other medical history includes a remote splenectomy and hypertension. A gram stain of the patient's cerebrospinal fluid is shown in Figure A. Of note, the patient's serum glucose at this visit is 120 mg/dL. Which of the following findings would be expected on further analysis of this patient's cerebrospinal fluid?	Neurologic Sciences	Meningitis	L 1	A
63	IM.203	206230	A 45-year-old male presents to the emergency room following a seizure. The patient suffered from an upper respiratory infection complicated by sinusitis two weeks ago. The patient's past medical history is remarkable for hypertension for which he takes hydrochlorathiazide. Temperature is 39.5C, blood pressure is 120/60 mmHg, pulse is 85/min, and respiratory rate is 20/min. Upon interview, the patient appears confused and exhibits photophobia. CSF cultures are obtained. Which of the following is the most appropriate next step in the management of this patient?	Neurologic Sciences	Meningitis	L 1	A
64	IM.4691	207598	A 49-year-old woman with a history of hepatitis C cirrhosis complicated by esophageal varices, ascites, and hepatic encephalopathy presents with 1 week of increasing abdominal discomfort. Currently, she takes lactulose, rifaximin, furosemide, and spironolactone. On physical examination, she has mild asterixis, generalized jaundice, and a distended abdomen with positive fluid wave. Diagnostic paracentesis yields a WBC count of 1196/uL with 85% neutrophils. Which of the following is the most appropriate treatment?	Gastroenterology	Cirrhosis	L 1	A
65	IM.4694	207874	A 56-year-old African American male presents with altered mental status, abdominal pain, and a fever of 100.4F. His past medical history is significant for alcohol use and cirrhosis of the liver. Shifting dullness is noted on physical exam. Paracentesis demonstrates serum ascites albumen gradient of 1.3 g/dL, and the ascitic fluid polymorphonuclear cell count is 280 cells/mm^3. Which of the following is the best treatment for this patient’s condition while waiting for the ascitic fluid culture results?	Gastroenterology	Spontaneous Bacterial Peritonitis (SBP)	L 1	A
66	IM.70	204861	A 32-year-old female presents to the emergency room with jaundice and altered mental status. She is afebrile with all other vital signs normal. When she extends her wrists her hands tremor. Initial labs reveal markedly elevated transaminases and prolonged prothrombin time. Total bilirubin is 6mg/dL and serum creatinine is 3 mg/dL. The patient's husband reports that she pricked herself with a needle in a hospital where she was volunteering several weeks ago. She is admitted to the intensive care unit with institution of supportive cares, but her condition continues to deteriorate, with further elevation in her bilirubin and INR and worsening encephalopathy. What is the appropriate next step in management?	Gastroenterology	Fulminant Liver Failure	L 1	A
67	IM.14	204805	A 62-year-old white male presents to a primary care doctor with concern for weight gain, abdominal distension, and breast enlargement. Physical exam reveals an overweight male with bilateral gynecomastia and a distended abdomen with evidence of shifting dullness. You also note several skin lesions as demonstrated in Image A. The patient has a past medical history of recurrent gout and Wernicke encephalopathy. Which aspect of the patient's history would reveal the most-likely underlying cause of the patient's chief complaints?	Gastroenterology	Cirrhosis	L 1	A
68	IM.43	204490	A 56-year-old homeless male presents to a free clinic for a health evaluation. He states that he has not seen a physician in over 25 years but finally decided to seek medical attention after he noticed recent chronic fatigue and weight gain. Upon questioning, he endorses drinking 2 handles of whiskey per day. On exam, the physician observes the findings shown in Figures A-D. Which of the following findings would also be expected to be observed in this patient?	Gastroenterology	Alcoholic Liver Disease	L 1	A
69	IM.185	205583	A 5-year-old boy accompanied by his mother presents to the pediatrician for his yearly exam. His medical history is notable for a mutation in the gene for clotting factor VIII, for which he is followed by a hematologist. His mother reports that the boy has required hospitalization for administration of factor VIII concentrate following minor trauma twice in the last year. The patient reports no current complaints and wants to return to kindergarten for the day. Which of the following would be consistent with the boy's diagnosis?	Hematology	Hemophilia	L 1	A
70	IM.36	204361	A 63-year-old man with chronic constipation presents to his primary care physician complaining of blood in his eye. He noticed that his eye was red when he awoke this morning. He denies any eye trauma, itching, burning, pain, or change in vision. His eye is shown in Figure A. What is the most appropriate next step?	Opthalmology	Subconjunctival Hemorrhage	L 1	A
71	IM.7	205677	A 30-year-old female is brought to the emergency department (ED) by her husband after refusing to sleep for a week and spending the couple’s entire savings account on a collection of fur coats. In the ED, the patient refuses physical examination and insists that she wear a black sequin dress rather than a hospital gown. For several hours, the patient is overcome by fits of laughter and refuses to answer questions. She then insists that she be allowed to leave the hospital immediately. Urine toxicology is negative. Which class of drugs should be administered?	Psychiatry	Bipolar Disorder	L 1	A
72	IM.4	203739	A 62-year-old man with a history of bipolar disorder, hypertension, atrial fibrillation, hyperlipidemia, and diabetes presents to his primary care physician for a routine checkup. Upon chart review it is noted that the patient is largely noncompliant with his medications except for his lithium, which he takes religiously. If the patient is restarted on his medications, which of the following could cause a significant lithium toxicity?	Psychiatry	Lithium	L 1	A
73	IM.82	206927	A 63-year-old patient with a history of bipolar I disorder is admitted to an inpatient psychiatric ward after a suicide attempt. She reports that she has attempted suicide 7 times, usually overdosing on whatever pills she has "lying around the house." During which of the following mood states is a patient with bipolar I disorder most likely to attempt suicide?	Psychiatry	Bipolar Disorder	L 1	A
74	IM.8	205825	A 35-year-old female presents to her PCP at the request of her husband after 3 weeks of erratic behavior. The patient has been staying up all night online shopping on eBay. Despite a lack of sleep, she is "full of energy" during the day at her teaching job, which she believes is "beneath [her], anyway." She has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. The patient denies thoughts of suicide. Pregnancy test is negative. Which of the following is the best initial treatment?	Psychiatry	Bipolar Disorder	L 1	A
75	IM.50	204935	A 63-year-old gentleman with a history of mitral valve prolapse presents to his internist with a 2-week history of fever, night sweats, and general malaise. Three weeks ago, he underwent periodontal surgery for gingival hyperplasia, for which he did not receive antibiotic prophylaxis. He denies a history of drug abuse. His physical exam is notable for a temperature of 39 deg C and a faint pansystolic murmur loudest at the cardiac apex. His nails are shown in Figure A, and painful lesions on his fingers are shown in Figure B. What is the most likely causative organism in this case?	Cardiovascular	Endocarditis	L 1	A
76	IM.18	204903	A 37-year-old man with a history of IV drug use presents to the ED with complaints of fevers, chills, and malaise for one week. He admits to recently using IV and intramuscular heroin. Vital signs are as follows: T 40.0 C, HR 120 bpm, BP 110/68 mmHg, RR 14, O2Sat 98%. Examination reveals a new systolic murmur that is loudest at the lower left sternal border. Initial management includes administration of which of the following regimens?	Cardiovascular	Endocarditis	L 1	A
77	IM.6	203297	A 76-year-old male with a history of hypertension, CAD, and asthma presents to the emergency department with abdominal pain and lightheadedness. He states that his symptoms began suddenly an hour ago leading him to seek care in the ED. Upon questioning, he has a 35-pack-year smoking history and has not seen a primary care physician in over 20 years. His ED vitals are given: T: 36 deg C, HR: 110 bpm, BP: 90/50, RR: 14, SaO2: 97% and the findings shown in Figure A are observed. An EKG is immediately obtained which is demonstrated in Figure B. Concomitantly with gaining IV access and performing volume resuscitation, what diagnostic test should be performed immediately?	Cardiovascular	Abdominal Aortic Aneurysm	L 1	A
78	IM.4694	207757	A 38-year-old female presents to the emergency room with fevers, fatigue, and anorexia for over a month. Past medical history includes mild mitral valve prolapse. She underwent an uncomplicated tooth extraction approximately 6 weeks ago. Her vital signs include a temperature of 100.8 F, pulse of 83, blood pressure of 110/77, and SpO2 of 97% on room air. On exam, you note a grade III/VI holosystolic murmur at the apex radiating to the axilla as well as several red, painful nodules on her fingers. Which of the following is the next best course of action?	Cardiovascular	Endocarditis	L 1	A
79	IM.5	202723	A 32-year-old woman presents to your office with a one month history of heat intolerance, racing heart, unintentional 4 pound weight loss, and sweating. On physical examination there is a non-tender enlarged thyroid without evidence of proptosis or exophthalmos. Lab tests return with increased total T4, decreased TSH, and increased free T4. A radioactive iodine uptake exam is ordered and the imaging is displayed in Figure A. What is the most appropriate definitive treatment option for this patient?	Endocrinology	Graves Disease	L 1	A
80	IM.1	204275	A 67-year-old female presents with complaints of fatigue, nausea, and headache that have developed over the past several weeks. Her past medical history is significant for hypertension, diabetes mellitus, CHF, and small cell lung cancer diagnosed and treated 3 years previously. Vital signs are as follows: T 37.3 C, HR 82, BP 142/86, RR 16, O2Sat 97% on RA. On physical exam, peripheral edema is absent, and she is alert and oriented to person, place, and time. Abnormalities noted on initial labwork include glucose 138 mg/dL and sodium 122 mEq/L. Follow-up testing reveals a urine osmolality of 310 mmol/kg and a serum osmolality of 268 mmol/kg; BUN and creatinine levels are within normal limits. Which of the following is the best next step in the management of this patient?	Endocrinology	Syndrome of Inappropriate ADH (SIADH)	L 1	A
81	IM.102	204427	A 27-year-old female presents to the emergency room with palpitations. Vitals are stable with the exception of tachycardia. On physical examination, she appears gaunt but has no goiter or proptosis. Serum thyroglobulin and TSH are low. T3 is elevated. A radioactive iodine study is performed which shows low uptake in the thyroid gland. What is the most likely diagnosis?	Endocrinology	Hypothyroidism vs. Hyperthyroidism	L 1	A
82	IM.149	204155	A 79-year-old man presents to the general medical clinic with syncope. His wife reports that she was walking with him when he abruptly lost consciousness and dropped to the ground. He has no significant past medical history. Vital signs are stable. On physical examination, he has a late peaking systolic murmur. A2 is barely detectable. You also note that on cardiac auscultation there is a significant delay between his heart sounds and palpating his carotid pulse. EKG shows the following (figure A). Regarding this patient, what does the EKG depict and what is the most likely underlying cause of his illness?	Cardiovascular	Aortic Stenosis	L 1	A
83	IM.4691	207607	A 74-year-old woman with no significant past medical history presents with 1 week of fever, unremitting headache and hip and shoulder stiffness. She denies any vision changes. Physical examination is remarkable for right scalp tenderness and range of motion is limited due to pain and stiffness. Neurological testing is normal. Laboratory studies are significant for an erythrocyte sedimentation rate (ESR) at 75 mm/h (normal range 0-22 mm/h for women). Which of the following is the most appropriate next step in management?	Rheumatology	Giant Cell Arteritis	L 1	A
84	IM.2	203293	A 47-year-old male presents with pain and swelling in his great toe for three days duration. He has never had similar symptoms. He his afebrile, but has erthema and warmth over his great toe. A clinical image is shown in Figure A and a radiograph is shown in Figure B. Serum laboratory levels show a elevated uric acid level. The joint is aspirated, and crystal analysis is shown in Figure C. What is the most appropriate first line of treatment.	Rheumatology	Gout	L 1	A
85	IM.1	203292	A 60-year-old man presents with pain and swelling in his great toe of three days duration. He has never had these symptoms before. On physical exam he is afebrile, and has erythema over the great toe. A clinical image is shown in Figure A. Which of the following laboratory or imaging results would confirm the diagnosis of acute gout in this patient?	Rheumatology	Gout	L 1	A
86	IM.4684	207354	A 56-year-old woman with a history of alcoholic cirrhosis and recurrent esophageal varices who recently underwent transjugular intrahepatic portosystemic shunt (TIPS) placement is brought to the emergency room by her daughter due to somnolence. Starting this morning, the patient has appeared sleepy, difficult to arouse, and slow to respond to questions. On physical exam, temperature is 98.6 deg F (37 deg C), blood pressure is 98/56 mmHg, pulse is 72/min, and respirations are 14/min. She repeatedly falls asleep and does not cooperate with asterixis testing. Pupils contract rhythmically to penlight exam. Which of the following is the most appropriate treatment?	Gastroenterology	Hepatic Encephalopathy	L 1	A
87	IM.4694	207756	A 32-year-old female presents to the emergency department with abdominal pain and new onset itching all over. The patient has experienced recurrent abdominal discomfort, but was unable to get care due to lack of insurance. More recently, she has noticed the onset of pale-tan colored stools, and dark yellow urine. Vitals are T 101.0 F HR 93 bmp BP 126/93 mmHg RR 15 rpm SpO2 98% On physical exam, sclera are notably icteric. Abdominal exam demonstrates right upper quadrant and epigastric tenderness without guarding or rebound. Endoscopic retrograde cholangiopancreatography (ERCP) is shown in Figure A. Which of the following lab findings are most likely present?	Gastroenterology	Choledocholithiasis	L 1	A
88	IM.26	204666	A 32-year-old male presents to his family physician for a check-up. His medical history is significant for recurrent cholelithiasis in childhood requiring a cholecystectomy at 15 years of age. He also reports that his father and paternal grandmother suffered from a 'blood disease'. Physical exam is significant for generalized pallor, jaundice, scleral icterus, and palpable splenomegaly. An office hemoglobin level is obtained and is 10 g/dL. Peripheral blood smear is conducted and shows small red blood cells lacking central pallor. A Coombs test is conducted and is negative. Which of the following complete blood count results is most consistent with this patient's likely diagnosis?	Hematology	Hereditary Spherocytosis	L 1	A
89	IM.6	205006	A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. He is noted to have distinct right facial paralysis. A non-contrast head CT is performed and is shown in Figure A. What is the most likely diagnosis in this case?	Neurologic Sciences	Stroke	L 1	A
90	IM.4688	207496	A 34-year-old male presents to clinic today complaining that his medication has stopped working. He states despite being able to manage the side effects, a voice has returned again telling him to hurt his Mother. You prescribe him a drug which has shown improved efficacy in treating his disorder but requires frequent followup visits. One week later he returns with the following lab results: WBC : 2500 cells/mcL, Neutrophils : 55% and, Bands : 1%. What drug was this patient prescribed?	General	Psychiatric Medications	L 1	A
91	IM.4672	207183	A 16-year-old male high school basketball player presents to his primary care provider with complaints of fatigue and night sweats for the past month. He also recalls that, after suffering a hand laceration during a game, the nurse had a difficult time achieving hemostasis. Otherwise, the patient has no other medical problems. Three weeks later, the patient is admitted to the ICU with decreased level of consciousness. Vital signs are: T 98.7 F, HR 110, BP 96/72, RR 18, SpO2 96%. CBC shows WBC 10, Hgb 9, Hct 35, and Plt 75. PT and PTT values are elevated. The following findings are seen on examination of the patient’s skin (Figure A). Peripheral blood smear reveals the following cell morphologies (Figure B). What is the underlying cause of this patient’s presentation?	Hematology	Disseminated Intravascular Coagulation (DIC)	L 1	A
92	IM.3	205003	A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable only for hypertension. On physical exam, vital signs are within normal limits except for a heart rate of 105 bpm. He is noted to have distinct right facial paralysis. Which of the following is the next best step in the management of this patient?	Neurologic Sciences	Stroke	L 1	A
93	IM.62	203353	A 25-year-old woman comes into your office with complaints of heavy bleeding. She states that her mother also has heavy bleeding during her menstrual cycle. She has had a heavy flow as long as she can remember and had her first menstrual cycle at age 12. She states during her cycle, she has to change pads every 2 hours for at least 3 days. She also states that she gets bruised easily just like her mother. She denies any past medical history other than her heavy menstrual flow and denies taking any medications. She also denies any medical history in her father and says he is "perfectly healthy." Her vitals are HR 85, T 98.8 F, RR 13, BP 125/75. Her CBC is significant for Hgb 10.5, WBC 5.8, Plts 250, Hct 33. On coagulation studies, her PT is 14 seconds and her PTT is 43 seconds. Her INR is 1.1. What is the most likely cause of this patient's menorrhagia?	Hematology	Von Willebrand Disease	L 1	A
94	IM.19	204659	A woman brings her 4-day-old son to the emergency room. She is concerned because he has had a difficult-to-control nosebleed, persistent bleeding from his umbilical stump, and red streaks in his diaper. The woman reports that she had an uneventful pregnancy followed by an attended home birth in which all post-natal injections were refused. Which of the following lab findings would you expect to find in this newborn?	Hematology	Coagulation Cascade	L 1	A
95	IM.10	203033	A 40-year-old female visits the emergency department with right upper quadrant pain and fever of 2-hours duration. She denies alcohol, cigarette, and drug use and reports no other medical problems. Body mass index is 30 kg/m^2. Her temperature is 38.5 degrees Celsius (101.3 degrees Fahrenheit), blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 18/min. Jaundice is present in the sclera and at the base of the tongue. The abdomen is tender in the right upper quadrant. Liver function test (LFTs) reveal elevated direct and total bilirubin and alkaline phosphatase of 500 U/L. IV Ampicillin-gentamicin is administered, fluid resuscitation is initiated, and over 24 hours the patient’s fever improves. Which of the following is the next step in the management of this patient:	Gastroenterology	Ascending Cholangitis	L 1	A
96	IM.35	203058	A 48-year-old female presents to the emergency department with fevers, and worsening abdominal pain for 24 hours. Exam demonstrates an overweight female in distress. Abdominal exam is notable for tenderness to palpation in the right upper quadrant and a positive ultrasonic (US) murphy's sign. Right upper quadrant ultrasound is shown in Figure A. Vital signs are as follows: T 102.1 F HR 84 BP 135/92 RR 14 O2 Sat 97%. Lab studies demonstrate leukocytosis. What's the next best step in management?	Gastroenterology	Acute Cholecystitis	L 1	A
97	IM.101	204741	A 25-year-old female with no significant past medical history presents to her primary care physician with several weeks of increased fatigue and decreased exercise tolerance. On physical exam, her skin and conjunctiva appear pale. The physician suspects some form of anemia and orders a complete blood panel, which is remarkable for hemoglobin 11.7 g/dl, MCV 79 fL, MCHC 38% (normal 31.1-34%), and reticulocyte index 3.6%. Peripheral blood smear shows red blood cells with a lack of central pallor. This patient would most likely develop which of the following conditions?	Hematology	Hereditary Spherocytosis	L 1	A
98	IM.22	205659	A 27-year-old G1P0 female presents for her first prenatal visit. She is in a monogamous relationship with her husband, and has had two lifetime sexual partners. She has never had a blood transfusion and has never used injection drugs. Screening for which of the following infections is most appropriate to recommend this patient?	General	Prenatal Care	L 1	A
99	IM.19	204810	A 41-year-old woman presents to the emergency department with severe, sudden-onset abdominal pain. She points to the right upper quadrant of her abdomen when asked to localize the pain, but she also reports pain in her upper back. The pain began approximately 30 minutes after she had eaten lunch, and she vomited twice on her way to the hospital. Physical exam reveals an obese female with RUQ abdominal tenderness to palpation. Her vital signs are as follows: T 38.1, HR 99, BP 144/87, RR 22, O2 Sat 96% RA. An abdominal ultrasound is conducted and is shown in Figure A. Upon review of her medication list, which of the following agents could have most likely increased this patient's risk for developing her presenting condition?	Gastroenterology	Acute Cholecystitis	L 1	A
100	IM.4694	207738	A 42-year-old female presents to the emergency department with two days of severe abdominal pain and fever. The patient has a history of gallstones, for which she was scheduled to have a cholecystectomy in two weeks. On physical exam, her abdomen is tender to palpation over the epigastrium, without rebound or guarding. The patient is noticeably jaundiced. Laboratory evaluation is notable for a leukocytosis and a total bilirubin of 6.4 mg/dL. What is the diagnosis in this patient?	Gastroenterology	Ascending Cholangitis	L 1	A
101	IM.5383	206990	A 34-year-old female presents to her ophthalmologist with 6 hours of blurry vision in her right eye. She reports severe pain with eye movement that has not been relieved with NSAIDs. She feels that she has been generally healthy all her life, although she does note one week of right arm weakness during the previous year that resolved without treatment. On exam, she has no noted ocular secretions, and her fundal exam is shown in Figure A. Which of the following additional findings is likely to be present in this patient?	Neurologic Sciences	Multiple Sclerosis	L 1	A
102	IM.16	205833	A 33-year-old male with a history of HIV presents to the emergency department at the urging of his friends with a 1-week history of fever, severe headache, and neck pain. Per his friends, this morning he awoke and seemed very confused. According to the the patient's records, his most recent CD4+ count 2 weeks ago was 34 and he admits to being poorly compliant on his HAART regimen because of the side effects. A lumbar puncture is performed which demonstrates severely elevated opening pressure, increased lymphocytes, elevated protein, and decreased glucose. An MRI is also obtained which demonstrates the findings shown in Figure A and CSF culture ultimately yields the results in Figure B. What is the best initial management of this patient?	Infectious Dis.	Opportunistic Mycoses	L 1	A
103	IM.3	204277	A 64-year-old man presents for a routine physical. He states that he is not doing very well and, in fact, has not had a bowel movement in over a week. Upon further questioning, the patient notes that for about 4 months he has experienced significant back pain and finds that he is easily fatigued. His wife has remarked that he is unusually "pale." In addition to his lack of a bowel movement for the past week, the patient has also had a loss of appetite, has been urinating more than usual, and has had a depressed mood. Which of the following is the most likely cause of this patient's constipation?	General	Electrolyte Disturbances	L 1	A
104	IM.38	204249	After spending a day at the beach, a 70-year-old woman notices a large bruise on her forearm. She doesn't recall any trauma to the area, but has had similar lesions in the past that resolved without intervention. She is otherwise healthy and is not taking any medications. Figure A demonstrates her physical exam findings. What is the most likely diagnosis?	Dermatology	Senile Purpura	L 1	A
105	IM.4694	207816	A 1-week old child is brought into your office for a normal check-up when you notice bruising on his arm. The mother states the child was born at home and had a "natural birth". She also states that the child is eating and having yellow seedy stools 4-8 times per day. She took lamotrigine for her seizures, but she had regular check-ups and was told everything was normal. She does state that she has noticed that the child bruises easily. On exam, the vitals are normal, but the child has pin-point spots on his arms where he was held by the mother that do not disappear with pressure (Figure A). His PT and aPTT are elevated, but the bleeding time is normal. What is the most likely diagnosis?	General	Vitamin K	L 1	A
106	IM.13	202731	A 34-year-old female presents to her ophthalmologist with 6 hours of blurry vision in her right eye. She reports severe pain with eye movement that has not been relieved with NSAIDs. She feels that she has been generally healthy all her life, although she does note one week of right arm weakness during the previous year that resolved without treatment. On exam, she has no noted ocular secretions, and her fundal exam is normal. Which of the following diagnostic modalities would be most likely to reveal additional findings?	Neurologic Sciences	Multiple Sclerosis	L 1	A
107	IM.111	205781	A 65-year-old man presents to general medical clinic with a chief complaint of a sleep disturbance. For the past 7 months, he has been having problems with early morning wakening. Review of systems also reveals a loss of energy, inability to concentrate in his job, weight loss, and a feeling of guilt for his daughter's unemployment. The first line treatment for this patient's problems would be which of the following drugs?	Psychiatry	Major Depressive Disorder	L 1	A
108	IM.81	206934	A 63-year-old man with a past medical history of schizophrenia is brought to the emergency room by his daughter after he wandered off from her home for several days. He appears disheveled, has a strong body odor, and has lost 10 pounds since his previous visit 1 month ago. He is prescribed quetiapine, but his daughter reports that she has difficulty making sure that he takes his medications every day. Which of the following medications may be most appropriate for this patient?	Psychiatry	Schizophrenia	L 1	A
109	IM.10	205620	A 29-year-old woman with a past medical history of depression is brought in by her boyfriend to the emergency department. He tells you that the two of them had a fight earlier in the day and then he saw her swallow a handful of pills that evening, approximately 1 hour ago. He does not know what medication she ingested, and she is uncooperative with your questioning or exam. You are able to call the local pharmacy and are told that she last filled her prescription for amitriptyline 1 week ago. Which of the following is the best indicator of the severity of intoxication in the setting of amitriptyline overdose?	Psychiatry	Tricyclic Antidepressants (TCAs)	L 1	A
110	IM.15	205685	A 25-year-old female with a history of schizophrenia presents to her physician complaining of milky discharge from both breasts. The patient’s medication regimen includes haloperidol. Blockade of which of the following neurotransmitters is responsible for this patient's clinical presentation?	Psychiatry	Antipsychotics	L 1	A
111	IM.4681	207296	A 35-year-old male patient is brought into the emergency department by emergency medical services. The patient has a history of schizophrenia and is on medication per his mother. His mother also states that the dose of his medication was recently increased, though she is not sure of the specific medication he takes. His vitals are HR 110, BP 170/100, T 102.5, RR 22. On exam, he cannot respond to questions and has rigidity. His head is turned to the right and remains in that position during the exam. Labs are significant for a WBC count of 14,000 cells/mcL, with a creatine kinase (CK) level of 3,000 mcg/L. What is the best treatment for this patient?	Psychiatry	Antipsychotics	L 1	A
112	IM.2	205639	A 33-year-old man with a past medical history of depression is brought into the emergency department after being found in a confused state by his wife. The patient was recently initiated on imipramine for his depression, and his wife reports that she noticed the empty bottle on the couch when she found him. The patient appears drowsy and confused. Vital signs reveal that he is tachycardic and hyperthermic. An ECG is performed and is shown in Figure A. What is the best course of management for this patient?	Psychiatry	Tricyclic Antidepressants (TCAs)	L 1	A
113	IM.81	206924	An 18-year-old female with a history of major depression is rushed to the hospital by emergency medical services after being found on the floor of her bedroom, obtunded. Her father notes that the patient has been treated with an antidepressant for years, although he is unsure what medication she was currently taking. As the physician is speaking with the patient's father, the patient begins to have convulsions and ultimately passes away. Review of premorbid EKG shows prolonged QT interval. Overdose with which of the following medications is the most likely cause of this patient's condition?	Psychiatry	Tricyclic Antidepressants (TCAs)	L 1	A
114	IM.112	205782	A 27-year-old male recently diagnosed with schizophrenia 6 months ago presents to your office for a check-up. Upon diagnosis, the patient was started on a single medication for his psychiatric symptoms. Today, he complains of 20 pound weight gain over the prior six months. Laboratory studies reveal that serum LDL cholesterol has increased significantly over the same time interval. The patient’s side effects are typical of which of the following drugs?	Psychiatry	Antipsychotics	L 1	A
115	IM.23	203314	A 27-year old gentleman presents to the primary care physician with the chief complaint of "feeling down" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything "feels slower" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him?	Psychiatry	Major Depressive Disorder	L 1	A
116	IM.205	204211	A 59-year-old woman presents to the ED with palpitations, which she has never experienced before now. Her past medical history is notable for chronic obstructive pulmonary disease (COPD) for which she has been hospitalized once in the last year. On exam her T 98.4F, HR 86, BP 105/70, RR 18, SpO2 94% on room air consistent with her baseline. Her EKG is shown in Figure A. What is the most common site of origin for ectopic foci causing the arrhythmia in this patient?	Cardiovascular	Atrial Fibrillation	L 1	A
117	IM.3	203655	A 75-year-old male presents to the emergency room with dyspnea and palpitations. He says that for the past 6 hours he has felt unsteady on his feet and has struggled to catch his breath while sitting comfortably. History is significant for diabetes mellitus type II, hypertension, hyperlipidemia, heavy alcohol use, and a 30 pack-year smoking habit. Current medications include atorvastatin, lisinopril, hydrochlorothiazide, and glipizide. He is afebrile, blood pressure is 150/100 mmHg, pulse is 160 and irregular, and respiratory rate is 25/min. Heart sounds are normal, but wheezes are present in both lungs. A representative electrocardiogram (EKG) strip is shown in Figure A. Which of the following factors in the patient’s history is most contributory to his EKG findings:	Cardiovascular	Multifocal Atrial Tachycardia	L 1	A
118	IM.4691	207619	A 34-year-old male is brought to the emergency department. He has prior hospitalizations for opiate overdoses, but today presents with fever, chills, rigors and malaise. On physical exam vitals are temperature: 100.5 deg F (38.1 deg C), pulse is 105/min, blood pressure is 135/60 mmHg, and respirations are 22/min. You note the following findings on the patient's hands (Figures A and B). You note that as the patient is seated, his head bobs with each successive heart beat. Which of the following findings is most likely present in this patient?	Cardiovascular	Valvular Diseases	L 1	A
119	IM.37	203689	A 35-year-old male presents to the emergency room with shortness of breath dizziness, and palpitations. He has no other medical problems and denies the use of alcohol, tobacco, and drugs. He is afebrile, with a blood pressure of 110/70 mmHg, pulse of 180/min, and respirations of 21/min. Electrocardiogram demonstrates paroxysmal supraventricular tachycardia. The patient is given amiodarone, and his heart rate decreases to 74/min. The patient reports that he is feeling well and denies dizziness and palpitations. A new EKG shows the following tracing in lead V2 (Figure A). This patient’s pathology most likely stems from which of the following cardiac structures?	Cardiovascular	Wolff-Parkinson White (WPW) Syndrome	L 1	A
120	IM.105	204111	A 19-year-old college student is brought to the emergency room directly from his student health clinic. He has been experiencing fevers, chills, and neck stiffness for 24 hours. He is now photophobic and confused. In the emergency room, he is started on resuscitative IV fluids and undergoes a lumbar puncture. Immediately following, he is started on broad-spectrum antibiotics and admitted to the medical intensive care unit. Gram stain of the cerebrospinal fluid reveals gram negative diplococci. After receiving 3 L of normal saline, the patient's mean arterial pressure remains 55 mmHg and he is started on intravenous norepinephrine. On day 2 of the patient's hospital course you note diffuse, symmetric dusky discoloration of the finger tips. Which of the following is the likely cause of this new exam finding?	Cardiovascular	Septic Shock	L 1	A
121	IM.4694	207808	A 77-year-old male presents to the emergency department because of shortness of breath and chest discomfort. The patient states his ability to withstand activity has steadily declined, and most recently he has been unable to climb more than one flight of stairs without having to stop to catch his breath. On physical exam, the patient has a harsh crescendo-decrescendo systolic murmur heard over the right sternal boarder, with radiation to his carotids. Which of the following additional findings are most likely in this patient?	Cardiovascular	Aortic Stenosis	L 1	A
122	IM.4686	207369	A 35-year-old homeless male is admitted to your floor. The patient has a history of intravenous drug abuse and has been arrested multiple times for theft. The patient was recently living in a shelter when he started having fevers of up to 102.5 deg F (39.2 deg C). On admission, the patient's temperature is 102.4 deg F (39.2 deg C), blood pressure 100/65 mmHg, pulse 110/min, respirations 22/min. The patient is complaining of chest pain that has been ongoing for the last week. There is also a crescendo-decrescendo murmur present along the right sternal border with ECG as shown in Figure A. Blood cultures grow gram positive organisms that are catalase and coagulase positive. What is the best initial treatment for this patient?	Cardiovascular	Endocarditis	L 1	A
123	IM.4694	207867	A 74-year-old female with a history of hypertension, dyslipidemia, and osteoarthritis presents to her primary care physician because of worsening shortness of breath and intermittent chest discomfort. The patient reports that she is usually able to walk five blocks around her cul de sac, but lately this same walk causes her these symptoms. She also complains of mild chest pain that began yesterday. Vital signs are as follows: T 98.8 F, HR 90 bpm, BP 150/100 mmHG, RR 15, O2 Sat 96%. On exam, carotid pulses are noted to be delayed from the cardiac cycle. Cardiac auscultation is notable for a late-peaking crescendo-decrescendo systolic ejection murmur loudest over the right upper sternal border. The patient is referred to the emergency department, where cardiac enzymes are negative. An EKG is shown in Figure A. The patient is referred for an echocardiogram, and pressure gradient recordings across the aortic valve are shown in Figure B. Which of the following is the appropriate next step for this patient?	Cardiovascular	Aortic Stenosis	L 1	A
124	IM.4672	207178	An 11-year-old girl presents to her pediatrician with complaints of headache and rapid leg fatigue with exercise. Her vital signs are: HR 77, BP in left arm 155/100, RR 14, SpO2 100%, T 37.0 C. On palpation, her left dorsalis pedis pulse is delayed as compared to her left radial pulse. Her lower extremities feel slightly cool. Blood pressure obtained on the left lower extremity is 120/80. Which of the following is the most likely underlying pathology?	Cardiovascular	Coarctation of Aorta	L 1	A
125	IM.20	203672	A 78-year-old man presents to the emergency room with a three day history of palpitations. He denies dizziness, dyspnea, and chest pain, and says he sleeps comfortably on one pillow each night. His history is significant for diabetes mellitus type 2, hyperlipidemia, and hypertension. Medications include glyburide, lisinopril, and hydrochlorothiazide. The patient has a ten pack-year history of smoking but quit 15 years ago. He does not drink alcohol or use drugs. His heart rate is 115/min and his blood pressure is 145/95 mmHg. Physical examination demonstrates no evidence of heart failure. Electrocardiogram shows atrial fibrillation with rapid ventricular response. Which of the following is an appropriate therapy for this patient:	Cardiovascular	Atrial Fibrillation	L 1	A
126	IM.4698	208178	A 65-year-old man with hypertension and paroxysmal atrial fibrillation presents to his cardiologist for follow-up after recently starting metoprolol for rate control. His EKG shows an atrial rate of 260/min with ventricular rate of 50/min on an irregular baseline. An echocardiogram from his previous visit revealed no evidence of hypokinesis or hypertrophy with functionally intact valves. The patient does not drink alcohol and had no evidence of liver dysfunction in prior studies. What is the best medication for rhythm control in this patient?	Cardiovascular	Antiarrhythmics	L 1	A
127	IM.30	204355	A 44-year-old male presents to his primary care physician with complaints of fatigue, muscle weakness, cramps, and increased urination over the past several weeks. His past medical history is significant only for hypertension, for which he was started on hydrochlorothiazide (HCTZ) 4 weeks ago. Vital signs at today's visit are as follows: T 37.2, HR 88, BP 129/80, RR 14, and SpO2 99%. Physical examination does not reveal any abnormal findings. Serologic studies are significant for a serum potassium level of 2.1 mEq/L (normal range 3.5-5.0 mEq/L). Lab-work from his last visit showed a basic metabolic panel and complete blood count results to all be within normal limits. Which of the following underlying diseases most likely contributed to the development of this patient's presenting condition?	Endocrinology	Primary Hyperaldosteronism	L 1	A
128	IM.31	204356	A 37-year-old female presents to general medical clinic with headache, fatigue, and weakness. She also reports that she has been having to get up at night to urinate. She has no significant past medical history. She denies taking any medications. Her vital signs are stable with the exception of blood pressure of 165/100. Physical examination is unremarkable. She is concerned because she never remembers having high blood pressure. A workup of the patient's hypertension is initiated, and it is found that she has an elevated plasma ratio of aldosterone to renin. Which of the following would also be likely in this patient?	Endocrinology	Primary Hyperaldosteronism	L 1	A
129	IM.27	204352	A 62-year-old female presents to general medical clinic for health maintenance. She is due for a colonoscopy but before she schedules it, she would like to have a full exam. She has no complaints and no significant past medical history. She has been in good health for most of her life. Vital signs are stable. Her physical examination is benign. Routine labs reveal a calcium of 11.2 mg/dL. What is the next step in management?	Endocrinology	Hyperparathyroidism	L 1	A
130	IM.15	202747	A 62-year-old male is prescribed chemoprophylaxis following exposure to an infectious agent. He takes warfarin daily. Which of the following matches an organism with a prophylactic antibiotic appropriate for this patient?	Neurologic Sciences	Meningitis	L 1	A
131	IM.35	204826	A 46-year-old male with chronic hepatitis C (HCV), hypertension, and diabetes presents to his primary care physician for a follow-up visit to discuss possibly initiating HCV treatment. The physician reviews the patient's chart and sees that the he has a detectable level of serum HCV RNA and is currently compensating well for his liver disease. A liver biopsy is obtained which is demonstrated in Figure A. The physician reviews the benefits and potential side effects of initiating treatment with the patient. In this patient, which of the following are indications for initiating HCV treatment? (I) Age; (II) Serum HCV RNA level; (III) Liver biopsy findings; (IV) Compensation of liver disease	Gastroenterology	Chronic Hepatitis	L 1	A
132	IM.55	202684	A 64-year-old female presents to her primary care physician with complaints of fatigue, a sore mouth, as well as occasional abdominal pain and diarrhea for the past several months. She denies any loss of balance, trouble walking, numbness, pain, or tingling in her hands or feet. Physical examination is significant for mild hyperpigmentation of the dorsal aspect of the hands as well as a red, swollen tongue as shown in Figure A. A complete blood count reveals a hematocrit of 31 with a low reticulocyte count; in addition, a peripheral smear of the patient's blood is shown in Figure B. Further testing reveals normal serum methylmalonic acid levels and increased homocysteine levels. Which of the following medications likely increased this patient's risk of developing this presenting condition?	Hematology	Folic Acid Deficiency	L 1	A
133	IM.112	203475	A 52-year-old female presents to her rheumatologist with complaints of fatigue, a sore mouth, and occasional nausea and abdominal pain over the past several months. Her medical history is significant for 'pre-diabetes' treated with diet and exercise, hypertension managed with lisinopril, and rheumatoid arthritis well-controlled with methotrexate. Her vital signs are within normal limits. Physical examination is significant for an overweight female with the findings as shown in Figures A and B. The physician orders laboratory work-up including complete blood count with peripheral blood smear as well as basic metabolic panel and serum methylmalonic acid and homocysteine levels. These tests are significant for a hematocrit of 29.5, a decreased reticulocyte count, normal serum methylmalonic acid level, increased homocysteine level, as well as the peripheral smear shown in Figure C. Which of the following could have reduced this patient's risk of developing their presenting condition?	Hematology	Folic Acid Deficiency	L 1	A
134	IM.50	202991	A 35-year-old woman comes into the emergency room with complaints of fatigue. She states that over the last few days, she has been feeling tired and has had some bleeding in her mouth. She also states that she has started seeing "red dots" on her legs as illustrated in Figure A. She denies any cough, congestion, fever, diarrhea, headaches, or changes in urine production. On her exam, she has petechiae on her lower extremities, with active bleeding in her oropharynx. Her vitals are within normal limits. Her CBC is significant for WBC 7,500, Hgb 11.9, Hct 37, Platelets 45,000. Her LDH level is normal and her peripheral blood smear is shown in Figure B. What is the first line of treatment for this patient?	Hematology	Immune Thrombocytopenia (ITP)	L 1	A
135	IM.102	204742	A 45-year-old man is brought to the emergency room by his wife because he has been acting confused for the past day. He is febrile, with an oral temperature of 103.6 deg F; vital signs are otherwise stable. His physical exam is significant for the finding shown in Figure A; he has never noticed lesions like these before. He also has subtle right-sided weakness affecting upper and lower extremities. Labs reveal: hemoglobin 7.0 g/dL, hematocrit 21%, white blood count of 10.2 x 10^3 µL, and platelet count of 20 x 10^3 per µL. PT/INR and PTT are normal. A peripheral blood smear is shown in Figure B. What is the most likely diagnosis?	Hematology	Thrombotic Thrombocytopenic Purpura (TTP)	L 1	A
136	IM.4572	206986	A four-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow. She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding exclusively and feels that he has been feeding well. Which of the following is the most likely etiology of the patient's presentation?	Pediatrics	Neonatal Jaundice	L 1	A
137	IM.4678	207258	A 22-year-old female is hospitalized with fever and hypotension refractory to fluid resuscitation. Her vital signs are as follows: T 39.0 C, P 110, BP 86/52, RR 12, SpO2 98%. Physical exam reveals diffuse macular erythroderma (Figure A) and the following findings of the conjunctiva (Figure B) and oral cavity (Figure C). She complains of muscle aches as well as diarrhea for the past 3 days. She denies any recent travel or new sexual partners. She had her last menses 4 days ago and always uses a tampon. What is the most likely organism to cause this patient’s presentation?	Infectious Dis.	Toxic Shock Syndrome	L 1	A
138	IM.16	204901	A 67-year-old man presents with a hacking cough and fever. His health has been declining over the past several days. He is a smoker and has a history of chronic renal insufficiency. He works in a green house. He has no recent hospitalizations. His vital signs are temperature of 39 degrees celcius, heart rate 70 beats per minute, blood pressure of 140/90, respiratory rate of 22, and oxygen saturation of 90% on room air. On physical examination, he has diffuse crackles in both lungs. A basic metabolic profile and complete blood count are performed and reveal hyponatremia and leukocytosis. Which of the following is true of this illness?	Infectious Dis.	Legionnaires' Disease	L 1	A
139	IM.38	202979	A 33-year-old male presents to the emergency room with fatigue and a non-productive cough that started a month ago. Review of systems is positive for chills, fevers, and dyspnea on exertion. Vital signs are as follows: T 102.7 F, HR 90 bpm, BP 124/85 mmHg, RR 16 bpm. Physical examination reveals cervical lymphadenopathy. An HIV test returns positive. Chest radiography is performed and results are shown in Figure A. Which of the following diagnostic modalities is the most appropriate for this patient?	Infectious Dis.	Pneumocystis jiroveci Pneumonia (PCP)	L 1	A
140	IM.2	204887	A 32-year-old HIV positive female known to be non-adherent to her treatment regimen, presents to the hospital with the complaint of new-onset headaches. Her vital signs are only significant for a low-grade fever. Neurological examination reveals right-sided upper motor neuron signs, as well as a inattention and difficulty with concentration. The patient currently does not have a primary medical provider. A CT of the patients head is shown in the image below. What is the next best step in management for this patient?	Infectious Dis.	Human Immunodeficiency Virus (HIV)	L 1	A
141	IM.4692	207663	A 31-year-old female patient complains of numbness and tingling in her left hand, weakness, difficulty with walking, dizziness, and bladder dysfunction. She said that about a year ago, she had trouble with her vision, and that it eventually recovered in a few days. On physical exam, bilateral internuclear ophthalmoplegia, hyperreflexia in both patella, and bilateral clonus, are noted. A magnetic resonance imaging (MRI) study was done (Figure 1). If a lumbar puncture is performed in this patient, which of the following would most likely be found in cerebrospinal fluid analysis?	Neurologic Sciences	Multiple Sclerosis	L 1	A
142	IM.107	204747	A 51-year-old white female presents to her primary care physician for a regular check-up. She endorses eating a healthy diet with a balance of meat and vegetables. She also states that she has a glass of wine each night with dinner. As part of the evaluation, a complete blood count and blood smear were performed and are remarkable for: Hemoglobin 8.7 g/dL, Hematocrit 27%, MCV 111 fL, and a smear showing macrocytes and several hypersegmented neutrophils. Suspecting an autoimmune condition with anti-intrinsic factor antibodies, what other finding might you expect in this patient?	Hematology	B12 Deficiency / Pernicious Anemia	L 1	A
143	IM.4691	207621	A 73-year-old male presents to the ED with several days of fevers, cough productive of mucopurulent sputum, and pleuritic chest pain. He has not been to a doctor in 30 years because he “has never been sick”. His vital signs are: T 101F, HR 98, BP 100/55, RR 31. On physical exam he is confused and has decreased breath sounds and crackles on the lower left lobe. Gram positive diplococci are seen in the sputum. Which of the following is the most appropriate management for his pneumonia?	Infectious Dis.	Pneumonia	L 1	A
144	IM.94	204734	A 70-year-old female underwent a right total knee arthroplasty without complication. She was discharged to a rehab facility on post-operative day 3. Two days after her discharge from the hospital, she began experiencing pain and swelling of the right leg. Doppler ultrasound imaging at this time revealed a deep venous thrombosis in the right popliteal and tibial veins. The patient was re-admitted and started on an unfractionated heparin infusion. Five days later, doppler ultrasonography of the lower extremities revealed extension of the clot in the right lower extremity to include the common femoral, superficial femoral, popliteal, tibial, and saphenous veins. In addition, a thrombus was noted in the left common femoral vein as well. CBC showed a decrease in platelet count from 195,000/uL on admission to 83,000/uL. Which of the following is the pathophysiology of this patient's presentation?	Hematology	Heparin-Induced Thrombocytopenia (HIT)	L 1	A
145	IM.4688	207491	A 28-year-old female patient with a history of schizophrenia, type 2 diabetes mellitus, and hypothyroidism comes to clinic stating she would like to be put back on a medication. She recently stopped taking her haloperidol as it made it hard for her to "sit still." She requests to be put on olanzapine as a friend from a support group said it was helpful. Why should this medication be avoided in this patient?	General	Psychiatric Medications	L 1	A
146	IM.32	204243	A 65-year-old female is evaluated by her primary hospital team for the evaluation of a new rash. Approximately 1 week ago she was admitted for an exacerbation of chronic bronchitis and given trimethoprim/sulfamethoxazole (Bactrim). While her respiratory symptoms have improved, two days ago she developed a low-grade fever, a headache, and her eyes became red. Today she has a red rash on her face and chest. Additionally, she has numerous ulcers on her lips that were not there yesterday. On exam, she has scattered, irregularly shaped, dusky macules on her trunk and face - some are targetoid in nature. She also has mucosal involvement, with erosions and ulcers on her lips, inside her mouth, and around her eyes. What is the most likely diagnosis?	Dermatology	Stevens-Johnson Syndrome	L 1	A
147	IM.12	204652	An 82-year-old woman is brought to the ER after her neighbor saw her fall in the hallway. She lives alone and remarks that she's been feeling weak lately. She notes that she's been experiencing decreased appetite, palpitations, and fatigue. On exam, she is frail, with pale conjunctiva and tachycardia. Exam is otherwise normal. Her lab tests are notable for: Hgb 9.4, MCV 109, homocystine 15.1 micromol/L (normal range 5.8-11.9 micromol/L), and methylmalonic acid 0.2 micromol/L (normal range 0 - 0.4 micromol/L). Figure A shows her peripheral blood smear. Based on her presentation as well as this data, her physician suspects she is deficient in a nutrient. Body stores of this nutrient usually last how long?	Hematology	Folic Acid Deficiency	L 1	A
148	IM.37	204677	A 56-year-old female presents to your clinic 3 years after undergoing a partial gastrectomy for management of a gastrointestinal stromal tumor. The results of her complete blood count and blood smear, which were done prior to her visit today, are significant for: Hemoglobin 9 g/dL, Hematocrit 28%, MCV 112 fL, and a smear showing macrocytes and several hypersegmented neutrophils. Which of the following symptoms or physical exam findings might you expect in this patient?	Hematology	B12 Deficiency / Pernicious Anemia	L 1	A
149	IM.5	202946	A 55-year-old caucasian man presents to his primary care physician with a complaint of double vision, which started suddenly with no precipitating trauma. Twelve years ago, he presented to his physician with painful vision loss, which has since resolved. Since that initial episode, he had numerous episodes early-on in his disease course: two additional episodes of painful vision loss, as well as three episodes of right arm weakness and three episodes of urinary retention requiring catheterization. All of his prior episodes responded to supportive therapy and steroids. Which of the following features of this patient's disease is linked to a more benign disease course?	Neurologic Sciences	Multiple Sclerosis	L 1	A
150	IM.33	204575	A one-week-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her daughter's skin appears yellow. She reports that the child cries several times per day and sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding exclusively and feels that he has been feeding well. Which of the following is the best treatment for this condition?	Pediatrics	Neonatal Jaundice	L 1	A

2012 matches found 1 ...