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A 50-year-old woman presents with esophageal varices, alcoholic cirrhosis, hepatic encephalopathy, portal hypertension, and recent onset confusion. The patient’s husband does not recall her past medical history but knows her current medications and states that she is quite disciplined about taking them. Current medicat... | Abdominal paracentesis | step1 | C | Noncontrast CT of the head | Therapeutic trial of lactulose | Abdominal paracentesis | Serum ammonia level | en |
A 23-year-old woman is brought to the emergency department 8 hours after the sudden onset of shortness of breath and pleuritic chest pain. She has cystic fibrosis and, during the past year, has had 4 respiratory exacerbations that have required hospitalization. Current medications include an inhaled bronchodilator, an ... | Apical subpleural cyst | step2&3 | C | Bronchial hyperresponsiveness | Infection with gram-negative coccobacilli | Apical subpleural cyst | Increased pulmonary capillary permeability | en |
A 61-year-old diabetic woman is brought to the emergency department with the complaint of multiple bouts of abdominal pain in the last 24 hours. She says that the pain is dull aching in nature, radiates to the back, and worsens with meals. She also complains of nausea and occasional vomiting. She has been hospitalized ... | Pancreatitis | step2&3 | C | Cholecystitis | Choledocholithiasis | Pancreatitis | Duodenal peptic ulcer | en |
An 82-year-old woman is admitted to the hospital because of wet gangrene on her right leg. Two days after admission, she becomes increasingly confused and tachypneic. She is intubated and ventilatory support is initiated. Her temperature is 39.6°C (102.5°F), pulse is 127/min, and blood pressure is 83/47 mm Hg. The vent... | Fluid in the alveolar space | step1 | D | Hyperinflation of the lungs | Emboli in the pulmonary vasculature | Abscess in the lung parenchyma | Fluid in the alveolar space | en |
A 57-year-old florist presents to his family physician with nodular lesions on his right hand and forearm. He explains that he got pricked by a rose thorn on his right "pointer finger" where the first lesions appeared, and the other lesions then began to appear in an ascending manner. The physician prescribed a medicat... | Inhibits ergosterol synthesis | step1 | A | Inhibits ergosterol synthesis | Binds to ergosterol, forming destructive pores in cell membrane | Inhibits formation of beta glucan | Disrupts microtubule function | en |
A 58-year-old woman presents to the physician’s office with vaginal bleeding. The bleeding started as a spotting and has increased and has become persistent over the last month. The patient is G3P1 with a history of polycystic ovary syndrome and type 2 diabetes mellitus. She completed menopause 4 years ago. She took cy... | Endometrial biopsy | step2&3 | B | Hysteroscopy with dilation and curettage | Endometrial biopsy | Saline infusion sonography | Hysteroscopy with targeted biopsy | en |
A student is reviewing the various effects that can be plotted on a dose-response curve. He has observed that certain drugs can work as an agonist and an antagonist at a particular site. He has plotted a particular graph (as shown below) and is checking for other responses that can be measured on the same graph. He lea... | Non-competitive antagonist | step1 | B | Competitive antagonist | Non-competitive antagonist | Inverse agonist | Reversible antagonist | en |
You are seeing a patient in clinic who recently started treatment for active tuberculosis. The patient is currently being treated with rifampin, isoniazid, pyrazinamide, and ethambutol. The patient is not used to taking medicines and is very concerned about side effects. Specifically regarding the carbohydrate polymeri... | Vision loss | step1 | C | Cutaneous flushing | Paresthesias of the hands and feet | Vision loss | Arthralgias | en |
A 32-year-old man visits his primary care physician for a routine health maintenance examination. During the examination, he expresses concerns about not wanting to become a father. He has been sexually active and monogamous with his wife for the past 5 years, and they inconsistently use condoms for contraception. He t... | Explain the procedure's benefits, alternatives, and potential complications | step1 | B | Insist that the patient returns with his wife to discuss the risks and benefits of the procedure together | Explain the procedure's benefits, alternatives, and potential complications | Call the patient's wife to obtain her consent for the procedure | Discourage the patient from undergoing the procedure because his wife wants children | en |
A 48-year-old man is brought to the emergency department by his wife 20 minutes after she witnessed him vigorously shaking for about 1 minute. During this episode, he urinated on himself. He feels drowsy and has nausea. He has a history of chronic alcoholism; he has been drinking 15 beers daily for the past 3 days. Bef... | Osmotic myelinolysis | step2&3 | C | Cerebral edema | Hyperglycemia | Osmotic myelinolysis | Wernicke encephalopathy | en |
A 48-year-old man presents early in the morning to the emergency department with a burning sensation in his chest. He describes a crushing feeling below the sternum and reports some neck pain on the left side. Furthermore, he complains of difficulty breathing. Late last night, he had come home and had eaten a family si... | Fourth heart sound | step2&3 | D | Ejection systolic murmur | Expiratory wheezes | Fixed splitting of the second heart sound | Fourth heart sound | en |
A 76-year-old man is brought to the emergency room because of one episode of hemoptysis. His pulse is 110/min. Physical examination shows pallor; there is blood in the oral cavity. Examination of the nasal cavity with a nasal speculum shows active bleeding from the posterior nasal cavity. Tamponade with a balloon cathe... | Maxillary artery | step1 | D | Anterior cerebral artery | Facial artery | Occipital artery | Maxillary artery | en |
A researcher is studying how arachidonic acid metabolites mediate the inflammatory response in rats. She has developed multiple enzyme inhibitors that specifically target individual proteins in the arachidonic acid pathway. She injects these inhibitors in rats who have been exposed to common bacterial pathogens and ana... | Interleukin 8 | step1 | D | Interleukin 1 | Interleukin 4 | Interleukin 5 | Interleukin 8 | en |
A 23-year-old man comes to the physician because of recurrent episodes of chest pain, shortness of breath, palpitations, and a sensation of choking. The symptoms usually resolve with deep breathing exercises after about 5 minutes. He now avoids going to his graduate school classes because he is worried about having ano... | Diphenhydramine | step1 | A | Diphenhydramine | Naloxone | Fluoxetine | Ondansetron | en |
A 17-year-old girl with a BMI of 14.5 kg/m2 is admitted to the hospital for the treatment of anorexia nervosa. The patient is administered intravenous fluids and is supplied with 1,600 calories daily with an increase of 200 calories each day. On day 5 of treatment, the patient manifests symptoms of weakness and confusi... | Hypophosphatemia | step2&3 | C | Hypercalcemia | Hypermagnesemia | Hypophosphatemia | Thiamine deficiency | en |
A 25-year-old woman is brought to the emergency department after being involved in a rear-end collision, in which she was the restrained driver of the back car. On arrival, she is alert and active. She reports pain in both knees and severe pain over the right groin. Temperature is 37°C (98.6°F), pulse is 116/min, respi... | Posterior hip dislocation | step2&3 | D | Femoral neck fracture | Anterior hip dislocation | Femoral shaft fracture | Posterior hip dislocation | en |
An investigator is studying human genetics and cell division. A molecule is used to inhibit the exchange of genetic material between homologous chromosomes. Which of the following phases of the cell cycle does the molecule target? | Prophase I | step1 | C | Telophase I | Metaphase II | Prophase I | Anaphase I | en |
An investigator is studying neuronal regeneration. For microscopic visualization of the neuron, an aniline stain is applied. After staining, only the soma and dendrites of the neurons are visualized, not the axon. Presence of which of the following cellular elements best explains this staining pattern? | Rough endoplasmic reticulum | step1 | D | Microtubule | Nucleus | Lysosome | Rough endoplasmic reticulum | en |
A 67-year-old woman presents to a surgeon with a painless, slowly growing ulcer in the periauricular region for the last 2 months. On physical examination, there is an irregular-shaped ulcer, 2 cm x 1 cm in its dimensions, with irregular margins and crusting over the surface. The woman is a fair-skinned individual who ... | Intrastrand cross-linking of thymidine residues in DNA | step1 | A | Intrastrand cross-linking of thymidine residues in DNA | Upregulation of expression of cyclin D2 | Activation of transcription factor NF-κB | DNA damage caused by the formation of reactive oxygen species | en |
A 67-year-old man presents to the physician with profuse watery diarrhea along with fever and crampy abdominal pain. He has been taking an antibiotic course of cefixime for about a week to treat a respiratory tract infection. At the doctor’s office, his pulse is 112/min, the blood pressure is 100/66 mm Hg, the respirat... | Identification of C. difficile toxin in stool | step2&3 | A | Identification of C. difficile toxin in stool | Colonoscopy | Abdominal X-ray | CT scan of the abdomen | en |
A 45-year-old man presents to the emergency department with fever and easy bruising for 3 days. He has had fatigue for 2 weeks. He has no past medical history, and takes no medications. Excessive bleeding from intravenous lines was reported by the nurse. He does not smoke or drink alcohol. The temperature is 38.2°C (10... | All-trans retinoic acid (ATRA) | step2&3 | A | All-trans retinoic acid (ATRA) | Hematopoietic cell transplantation | Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) | Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) | en |
A 2-month-old is brought to the physician for a well-child examination. She was born at 39 weeks gestation via spontaneous vaginal delivery and is exclusively breastfed. She weighed 3,400 g (7 lb 8 oz) at birth. At the physician's office, she appears well. Her pulse is 136/min, the respirations are 41/min, and the bloo... | Smiles in response to face | step2&3 | C | Absence of asymmetric tonic neck reflex | Monosyllabic babble | Smiles in response to face | Stares at own hand | en |
A 40-year-old female comes in with several months of unintentional weight loss, epigastric pain, and a sensation of abdominal pressure. She has diabetes well-controlled on metformin but no other prior medical history. She has not previously had any surgeries. On physical exam, her doctor notices brown velvety areas of ... | Cells with central mucin pool | step1 | A | Cells with central mucin pool | Keratin pearls | Psammoma bodies | Peyer's patches | en |
A 6-year-old boy is brought to the emergency room by ambulance, accompanied by his kindergarten teacher. Emergency department staff attempt to call his parents, but they cannot be reached. The boy’s medical history is unknown. According to his teacher, the boy was eating in the cafeteria with friends when he suddenly c... | Immediately administer epinephrine and sedate and intubate the patient | step1 | B | Continue calling the patient’s parents and do not intubate until verbal consent is obtained over the phone | Immediately administer epinephrine and sedate and intubate the patient | Obtain written consent to intubate from the patient’s teacher | Wait for the patient's parents to arrive, calm the patient, and provide written consent before intubating | en |
A 12-month-old boy is brought to the physician for a well-child examination. He was born at 38 weeks' gestation and was 48 cm (19 in) in length and weighed 3061 g (6 lb 12 oz); he is currently 60 cm (24 in) in length and weighs 7,910 g (17 lb 7 oz). He can walk with one hand held and can throw a small ball. He can pick... | Growth | step2&3 | B | Gross motor skills | Growth | Fine motor skills | Social skills | en |
A 27-year-old woman presents to the emergency department with right lower quadrant abdominal pain and vaginal spotting. She denies diarrhea, constipation, or blood in the stool. The medical history is unremarkable. She does not use tobacco or drink alcohol. She is sexually active with her husband and uses an IUD for co... | Positive urinary beta-HCG and no intrauterine mass | step2&3 | B | Physical examination reveals rebound tenderness and tenderness at McBurney’s point | Positive urinary beta-HCG and no intrauterine mass | Barium enema shows true diverticuli in the colon | Positive urinary beta-HCG and some products of conception in the uterus | en |
A 58-year-old man with a past medical history of diabetes, hypertension, and hyperlipidemia was brought into the emergency department by his wife after she observed him go without sleep for several days and recently open and max out several credit cards. She also reports that he has quit his bartending job and has been... | Valproic acid | step1 | A | Valproic acid | Lithium | Pregabalin | Lamotrigine | en |
A 42-year-old woman comes to the physician for the evaluation of a 1-month history of dull lower abdominal pain, decreased appetite, and a 5-kg (11-lb) weight loss. Physical examination shows no abnormalities. Pelvic ultrasonography shows bilateral ovarian enlargement and free fluid in the rectouterine pouch. Biopsy sp... | Gastric wall thickening | step1 | D | Decreased TSH levels | Increased testosterone levels | Dark blue peritoneal spots | Gastric wall thickening | en |
A 71-year-old man presents to the clinic with complaints of right wrist pain for 2 days. On examination, redness and swelling were noted on the dorsal aspect of his right wrist. He had pain with extreme range of motion of the wrist. His history includes 2 hip replacements, 2 previous episodes of gout in both first met... | IL-1 | step1 | A | IL-1 | IL-10 | INFγ | IL-5 | en |
A group of investigators have conducted a randomized clinical trial to evaluate the efficacy of adding a novel adenosine A1 receptor agonist to the standard anti-epileptic treatment in reducing the frequency of focal seizures. It was found that patients taking the combination regimen (n = 200) had a lower seizure frequ... | Chi-square test | step1 | B | Multiple linear regression | Chi-square test | Unpaired t-test | Analysis of variance | en |
A 39-year-old male presents to your office with nodular skin lesions that progress from his right hand to right shoulder. The patient reports that the initial lesion, currently necrotic and ulcerative, developed from an injury he received while weeding his shrubs a couple weeks earlier. The patient denies symptoms of r... | Ascending lymphangitis | step1 | D | Contact dermatitis | Hematogenous dissemination | Dermatophyte colonization | Ascending lymphangitis | en |
A 17-year-old Latin American woman with no significant past medical history or family history presents to her pediatrician with concerns about several long-standing skin lesions. She notes that she has had a light-colored rash on her chest and abdomen that has been present for the last 2 years. The blood pressure is 11... | Malassezia yeast | step2&3 | A | Malassezia yeast | Cutaneous T cell lymphoma | TYR gene dysfunction in melanocytes | Treponema pallidum infection | en |
A 45-year-old male presents to the emergency room complaining of severe diarrhea. He recently returned from a business trip to Bangladesh. Since returning, he has experienced several loose bloody stools per day that are accompanied by abdominal cramping and occasional nausea and vomiting. His temperature is 101.7°F (38... | Inhibition of 60S ribosomal subunit | step1 | D | ADP-ribosylation of elongation factor 2 | Stimulation of guanylyl cyclase | ADP-ribosylation of a G protein | Inhibition of 60S ribosomal subunit | en |
An 80-year-old woman seeks evaluation at an outpatient clinic for a firm nodular lump on the left side of her labia. The medical history is notable for hypertension, coronary artery disease status post CABG, and lichen sclerosus of the vagina that was treated with an over-the-counter steroid cream as needed. She first ... | Vulvar punch biopsy | step2&3 | D | HPV DNA testing | Estrogen level measurement | Pap smear | Vulvar punch biopsy | en |
A 75-year-old male is hospitalized for bloody diarrhea and abdominal pain after meals. Endoscopic work-up and CT scan lead the attending physician to diagnose ischemic colitis at the splenic flexure. Which of the following would most likely predispose this patient to ischemic colitis: | Obstruction of the abdominal aorta following surgery | step1 | C | Increased splanchnic blood flow following a large meal | Essential hypertension | Obstruction of the abdominal aorta following surgery | Juxtaglomerular cell tumor | en |
Two days following the home birth of her son, a mother brings the infant to the pediatric emergency room because of bilious vomiting. He is unable to pass meconium and his abdomen is distended. Endoscopic biopsy of the proximal colon demonstrates an absence of Meissner’s and Auerbach’s plexi in the bowel wall. Which of... | Hirschsprung’s disease | step1 | A | Hirschsprung’s disease | Ileocecal intussusception | Meckel’s diverticulum | Juvenile polyposis syndrome | en |
A 49-year-old man comes to the physician because of a 6-month history of increasing fatigue and reduced libido. He also complains of joint pain in both of his hands. His vital signs are within normal limits. Physical examination shows tanned skin and small testes. The second and third metacarpophalangeal joints of both... | Restrictive cardiomyopathy | step1 | B | Colorectal carcinoma | Restrictive cardiomyopathy | Pancreatic adenocarcinoma | Non-Hodgkin lymphoma | en |
A general surgery intern is paged to the bedside of a 59-year-old male who underwent a successful sigmoidectomy for treatment of recurrent diverticulitis. The patient's nurse just recorded a temperature of 38.7 C, and relates that the patient is complaining of chills. The surgery was completed 8 hours ago and was compl... | Monitor patient and administer acetaminophen | step2&3 | A | Monitor patient and administer acetaminophen | Prescribe diphenhydramine | Start supplemental oxygen by nasal cannula | Initiate broad spectrum antibiotics | en |
A 22-year-old man presents to the emergency department with anxiety. The patient states that he is very anxious and has not been able to take his home anxiety medications. He is requesting to have his home medications administered. The patient has a past medical history of anxiety and depression. His current medication... | Diazepam | step2&3 | A | Diazepam | Midazolam | Sodium bicarbonate | Supportive therapy and monitoring | en |
An 18-year-old female returning from a trip to a developing country presents with diarrhea and pain in the abdominal region. Microscopic evaluation of the stool reveals the presence of RBC's and WBC's. The patient reports poor sewage sanitation in the region she visited. The physician suspects a bacterial infection and... | Inhibit the 60S ribosome | step1 | A | Inhibit the 60S ribosome | Lyse red blood cells | Prevent phagocytosis | Inhibit exocytosis of ACh from synaptic terminals | en |
A 51-year-old man with a recent diagnosis of peptic ulcer disease currently treated with an oral proton pump inhibitor twice daily presents to the urgent care center complaining of acute abdominal pain which began suddenly less than 2 hours ago. On physical exam, you find his abdomen to be mildly distended, diffusely t... | Urgent CT abdomen and pelvis | step2&3 | B | Abdominal radiographs | Urgent CT abdomen and pelvis | H. pylori testing | Serum gastrin level | en |
A 31-year-old male presents to the emergency room following an altercation with patrons at a local grocery store. He is acting aggressively toward hospital staff and appears to be speaking to non-existent individuals. On examination he is tachycardic and diaphoretic. Horizontal and vertical nystagmus is noted. The pati... | NMDA receptor antagonist | step1 | D | Adenosine antagonist | Mu receptor agonist | GABA agonist | NMDA receptor antagonist | en |
A 29-year-old female presents to her primary care provider complaining of pain and stiffness in her hands and knees. She reports that the stiffness is worse in the morning and appears to get better throughout the day. She is otherwise healthy and denies any recent illness. She does not play sports. On examination, her ... | Synovial hypertrophy and pannus formation | step1 | D | Precipitation of monosodium urate crystals in the intra-articular space | Post-infectious inflammation of the articular surfaces | Degenerative deterioration of articular cartilage | Synovial hypertrophy and pannus formation | en |
A 28-year-old man presents for severe abdominal pain and is diagnosed with appendicitis. He is taken for emergent appendectomy. During the procedure, the patient has massive and persistent bleeding requiring a blood transfusion. The preoperative laboratory studies showed a normal bleeding time, normal prothrombin time ... | Hemophilia A | step2&3 | A | Hemophilia A | Bernard-Soulier syndrome | Glanzman syndrome | Thrombotic thrombocytopenic purpura | en |
An 11-year-old girl is brought to the emergency department because of high-grade fever, headache, and nausea for 3 days. She avoids looking at any light source because this aggravates her headache. She has acute lymphoblastic leukemia and her last chemotherapy cycle was 2 weeks ago. She appears lethargic. Her temperatu... | Antibiotic therapy | step2&3 | C | CT scan of the head | MRI of the brain | Antibiotic therapy | Lumbar puncture | en |
A 49-year-old man presents to a new primary care provider complaining of fatigue and occasional fever over the last month. These symptoms are starting to affect his job and he would like treatment. The physician runs a standard metabolic panel that shows elevated AST and ALT. The patient is then tested for hepatitis vi... | Hemolytic anemia | step1 | A | Hemolytic anemia | Drug-associated lupus | Hyperthyroidism | Rash | en |
A 45-year-old immigrant presents with unintentional weight loss, sleep hyperhidrosis, and a persistent cough. He says these symptoms have been present for quite some time. Upon imaging, many granulomas in the upper lobes are present. It is noted that these apical granulomas have centers of necrosis that appear cheese-l... | CD14 | step1 | D | CD8 | CD4 | CD3 | CD14 | en |
A 27-year-old woman comes to the emergency room because of fever and severe left knee pain for the past week. She has not sustained any trauma or injury to the area, nor has she traveled or taken part in outdoor activities in the recent past. She is sexually active with one male partner, and they use condoms inconsiste... | Intramuscular ceftriaxone and oral azithromycin | step2&3 | B | Oral penicillin V | Intramuscular ceftriaxone and oral azithromycin | Oral doxycycline | Intramuscular ceftriaxone | en |
A 30-year-old man presents with restlessness and an inability to sit or lie down for the past 2 days. Past medical history is significant for schizophrenia, diagnosed 3 weeks ago and managed medically. Vital signs are a blood pressure of 140/90 mm Hg and a pulse of 96/min. On physical examination, the patient is fidget... | Akathisia | step1 | D | Psychotic agitation | Essential tremor | Drug-induced parkinsonism | Akathisia | en |
In a previous experiment infecting hepatocytes, it was shown that viable HDV virions were only produced in the presence of a co-infection with HBV. To better understand which HBV particle was necessary for the production of viable HDV virions, the scientist encoded in separate plasmids the various antigens/proteins of ... | HBsAg | step1 | A | HBsAg | HBcAg | HBV RNA polymerase | HBeAg | en |
A 61-year-old woman presents to her primary care physician for a routine check-up. Physical examination demonstrates asymmetric peripheral neuropathy in her feet. The patient has no previous relevant history and denies any symptoms of diabetes. Routine blood work shows normal results, and she is referred to a hematolog... | Multiple myeloma | step1 | B | Waldenström macroglobulinemia | Multiple myeloma | Acute myelocytic leukemia | Chronic myelocytic leukemia | en |
A 71-year-old man presents to his primary care physician because he is increasingly troubled by a tremor in his hands. He says that the tremor is worse when he is resting and gets better when he reaches for objects. His wife reports that he has been slowing in his movements and also has difficulty starting to walk. His... | Alpha-synuclein | step1 | A | Alpha-synuclein | Intracellular hyperphosphorylated tau | Hyperphosphorylated tau inclusion bodies | Perivascular inflammation | en |
A 52-year-old man is brought to the emergency department while on vacation with a history of sudden onset vertigo and difficulty walking. He was in normal health since starting his vacation a week ago, but today he is suffering from a loss of balance, mild headache, and has had 5–6 episodes of vomiting over the last fe... | Inability to perform repetitive alternating movements | step2&3 | B | Inability to comprehend commands | Inability to perform repetitive alternating movements | Right-sided neglect | Right-sided visual field loss | en |
A 65-year-old man presents with painless swelling of the neck over the past week. He also has noted severe night sweats, which require a change of clothes and bed linens the next day. His medical history is significant for long-standing hypertension. He received a kidney transplant 6 years ago. His current medications ... | Non-Hodgkin’s lymphoma (NHL) | step2&3 | D | Drug-induced lymphadenopathy | Cytomegalovirus infection | Multiple myeloma | Non-Hodgkin’s lymphoma (NHL) | en |
A 56-year-old man is brought to the emergency department by his neighbor 2 hours after ingesting an unknown substance in a suicide attempt. He is confused and unable to provide further history. His temperature is 39.1°C (102.3°F), pulse is 124/min, respiratory rate is 12/min, and blood pressure is 150/92 mm Hg. His ski... | Physostigmine | step1 | B | Sodium bicarbonate | Physostigmine | Glucagon | Flumazenil | en |
An 81-year-old man presents to his primary care physician for his yearly exam. His past medical history is significant for osteopenia, nephrolithiasis, and hypertension. His family history is significant for relatives who had early onset kidney failure. He takes occasional acetaminophen and supplemental calcium/vitamin... | Normal aging | step1 | C | Benign prostatic hyperplasia | Nephrolithiasis | Normal aging | Renovascular disease | en |
A 72-year-old man presents to his primary care provider complaining of fatigue, mild headache, and discomfort with chewing for roughly 1 week. Before this, he felt well overall, but now is he is quite bothered by these symptoms. His medical history is notable for hypertension and hyperlipidemia, both controlled. On exa... | Blindness | step2&3 | B | Renal failure | Blindness | Pulmonary fibrosis | Cognitive impairment | en |
A 14-month-old boy is brought to the clinic for evaluation of a rash. The rash started on the face and spread to the trunk. He also had a fever and cough for the past 2 days. His mother says that they recently immigrated from Asia and cannot provide vaccination records. The physical examination reveals a maculopapular ... | ssRNA enveloped viruses | step1 | D | ssDNA enveloped viruses | ssRNA naked viruses | dsRNA naked viruses | ssRNA enveloped viruses | en |
A 31-year-old G1P0 woman at 26 weeks gestation presents to the clinic for evaluation of an abnormal glucose tolerance test. She denies any symptoms, but states that she was given 50 g of oral glucose 1 week earlier and demonstrated a subsequent venous plasma glucose level of 156 mg/dL 1 hour later. The vital signs are:... | Administer an oral, 3-hour 100 g glucose dose | step2&3 | B | Repeat the 50 g oral glucose challenge | Administer an oral, 3-hour 100 g glucose dose | Advise the patient to follow an American Diabetic Association diet plan | Begin insulin treatment | en |
A newborn of a mother with poor antenatal care is found to have a larger than normal head circumference with bulging fontanelles. Physical examination reveals a predominant downward gaze with marked eyelid retraction and convergence-retraction nystagmus. Ultrasound examination showed dilated lateral ventricles and a di... | Compression of periaqueductal grey matter | step1 | C | Normal lumbar puncture opening pressure | Dilated cisterna magna | Compression of periaqueductal grey matter | Hypertrophic arachnoid granulations | en |
A 22-year-old man comes to the physician because of a progressive swelling and pain in his right ring finger for the past 2 days. The pain began while playing football, when his finger got caught in the jersey of another player who forcefully pulled away. Examination shows that the right ring finger is extended. There ... | Rupture of the flexor digitorum profundus tendon at its point of insertion | step1 | A | Rupture of the flexor digitorum profundus tendon at its point of insertion | Closed fracture of the distal phalanx | Inflammation of the flexor digitorum profundus tendon sheath | Slipping of the central band of the extensor digitorum tendon | en |
A 50-year-old man comes to the physician for a routine checkup. He has had a progressively increasing swelling on the nape of his neck for 2 months. He does not have a fever or any discharge from the swelling. He underwent a colectomy for colon cancer at the age of 43 years. He has type 2 diabetes mellitus, hypertensio... | Epidermoid cyst | step2&3 | B | Actinic keratosis | Epidermoid cyst | Dermatofibroma | Squamous cell carcinoma
" | en |
A 67-year-old man comes to the physician because of a 3-day history of fever, chills, headache, and fatigue. He appears ill. His temperature is 39°C (102.2°F). Analysis of nasal secretions shows infection with an enveloped, single-stranded segmented RNA virus. In response to infection with this pathogen, certain cells ... | The molecule consists of a heavy chain associated with β2 microglobulin | step1 | B | The antigens are loaded onto the molecule within lysosomes | The molecule consists of a heavy chain associated with β2 microglobulin | The molecule is made up of 2 chains of equal length | The molecule is selectively expressed by antigen-presenting cells | en |
A 58-year-old female, being treated on the medical floor for community-acquired pneumonia with levofloxacin, develops watery diarrhea. She reports at least 9 episodes of diarrhea within the last two days, with lower abdominal discomfort and cramping. Her temperature is 98.6° F (37° C), respiratory rate is 15/min, pulse... | C. difficile colitis | step2&3 | B | Ulcerative colitis | C. difficile colitis | Irritable bowel syndrome | Giardiasis | en |
A 7-year-old girl presents to her primary care physician for a routine check-up. The physician allows the medical student to perform a physical examination. The medical student notes hearing impairment as well as the findings show in Figures A and B. Radiographs show indications of multiple old fractures of the humerus... | Deficiency of type 1 collagen | step2&3 | C | Decreased bone mineral density | Defective mineralization of cartilage | Deficiency of type 1 collagen | Dietary deficiency of ascorbic acid | en |
A 47-year-old man comes to the physician because of abdominal pain and foul-smelling, watery diarrhea for several days. He has not had nausea, vomiting, or blood in the stool. He has a history of alcohol use disorder and recently completed a 7-day course of clindamycin for pneumonia. He has not traveled out of the Unit... | Clostridioides difficile cytotoxin | step1 | D | Shiga toxin | Cholera toxin | Cereulide toxin | Clostridioides difficile cytotoxin | en |
A 6-year-old boy presents to the clinic because of monosymptomatic enuresis for the past month. Urinalysis, detailed patient history, and fluid intake, stool, and voiding diary from a previous visit all show no abnormalities. The parent and child are referred for education and behavioral therapy. Enuresis decreases but... | Enuresis alarm | step2&3 | C | Behavioral therapy | DDAVP | Enuresis alarm | Oxybutynin | en |
A 32-year-old homeless woman is brought to the emergency department by ambulance 30 minutes after the police found her on the sidewalk. On arrival, she is unresponsive. Her pulse is 76/min, respirations are 6/min, and blood pressure is 110/78 mm Hg. Examination shows cool, dry skin. The pupils are pinpoint and react sl... | μ-receptor | step1 | B | Ryanodine receptor | μ-receptor | GABAA receptor | 5-HT2A receptor | en |
An infectious disease investigator is evaluating the diagnostic accuracy of a new interferon-gamma-based assay for diagnosing tuberculosis in patients who have previously received a Bacillus Calmette-Guérin (BCG) vaccine. Consenting participants with a history of BCG vaccination received an interferon-gamma assay and w... | 90/100 | step1 | B | 194/200 | 90/100 | 90/96 | 194/204 | en |
Several patients at a local US hospital present with chronic secretory diarrhea. Although there are multiple potential causes of diarrhea present in these patients, which of the following is most likely the common cause of their chronic secretory diarrhea? | Medications | step1 | B | Lymphocytic colitis | Medications | Lactose intolerance | Carcinoid tumor | en |
A 27-year-old woman with sickle cell disease and at 39-weeks' gestation is brought to the emergency department in active labor. She has had multiple episodes of acute chest syndrome and has required several transfusions in the past. She has a prolonged vaginal delivery complicated by postpartum bleeding, and she receiv... | Positive direct Coombs test | step1 | B | Serum antibodies against class I HLA antigens | Positive direct Coombs test | Positive blood cultures | Low levels of serum IgA immunoglobulins | en |
A 17-year-old man is brought by his mother to his pediatrician in order to complete medical clearance forms prior to attending college. During the visit, his mother asks about what health risks he should be aware of in college. Specifically, she recently saw on the news that some college students were killed by a fatal... | More of them die from homicide than cancer | step1 | D | More of them die from suicide than injuries | More of them die from homicide than suicide | More of them die from cancer than suicide | More of them die from homicide than cancer | en |
A 7-month old boy, born to immigrant parents from Greece, presents to the hospital with pallor and abdominal distention. His parents note that they recently moved into an old apartment building and have been concerned about their son's exposure to chipped paint from the walls. On physical exam, the patient is found to ... | Microcytosis and hypochromasia of erythrocytes | step2&3 | B | Basophilic stippling of erythrocytes | Microcytosis and hypochromasia of erythrocytes | Schistocytes and normocytic erythrocytes | Sickling of erythrocytes | en |
A 51-year-old woman comes to the physician because of progressively worsening lower back pain. The pain radiates down the right leg to the lateral side of the foot. She has had no trauma, urinary incontinence, or fever. An MRI of the lumbar spine shows disc degeneration and herniation at the level of L5–S1. Which of th... | Weak achilles tendon reflex | step1 | C | Difficulty walking on heels | Exaggerated patellar tendon reflex | Weak achilles tendon reflex | Diminished sensation of the anterior lateral thigh
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A 52-year-old woman comes to the physician because of a 4-month history of progressive pain and stiffness of the fingers of her right hand that is worse at the end of the day. She works as a hair dresser and has to take frequent breaks to rest her hand. She has hypertension, for which she takes hydrochlorothiazide. Two... | Degenerative disease of the joints | step2&3 | C | Bacterial infection of the joint space | Autoimmune-mediated cartilage erosion | Degenerative disease of the joints | Calcium pyrophosphate dihydrate crystal precipitation in the joints | en |
A 51-year-old man presents to his dermatologist because of severe stomatitis and superficial skin erosions over his trunk. His condition started 2 months ago and was unresponsive to oral antibiotics and antiherpetic medications. He has no history of a similar rash. His medical history is remarkable for type 2 diabetes ... | Anti-desmoglein-3 antibodies | step2&3 | C | Increased mitotic activity of basal and suprabasal cells | Cutaneous T cell lymphoma | Anti-desmoglein-3 antibodies | Dermatophyte infection | en |
A 50-year-old male presents to his primary care physician for a routine check-up. He reports that he is doing well overall without any bothersome symptoms. His past medical history is significant only for hypertension, which has been well controlled with losartan. Vital signs are as follows: T 37.0 C, HR 80, BP 128/76,... | Secondary prevention | step1 | C | Primordial prevention | Primary prevention | Secondary prevention | Tertiary prevention | en |
A 57-year-old man presents to the emergency department because of pain in the center of his chest that is radiating down his left arm and up the left side of his neck. The pain started suddenly 30 minutes ago while the patient was at work. The patient describes the pain as squeezing in nature, 10/10 in intensity, and i... | Occlusion of the left anterior descending artery with rupture of a papillary muscle | step2&3 | A | Occlusion of the left anterior descending artery with rupture of a papillary muscle | Occlusion of the left anterior descending artery with interventricular septal rupture | Ventricular free wall rupture | Mitral leaflet thickening and fibrosis | en |
A 29-year-old African American female presents to your office with extreme fatigue and bilateral joint pain. Serologies demonstrate the presence of rheumatoid factor along with anti-Smith and anti-dsDNA antibodies. A VDRL syphilis test is positive. You order a coagulation profile, which reveals normal bleeding time, no... | History of multiple spontaneous abortions | step1 | D | Palmar rash | HLA-B27 positivity | Factor VIII deficiency | History of multiple spontaneous abortions | en |
A 31-year-old man comes to the physician because of a 5-day history of fever, chills, and dyspnea. His temperature is 38.9°C (102°F) and pulse is 90/min. Cardiac examination shows a murmur. In addition to other measures, cardiac catheterization is performed. A graph showing the results of the catheterization is shown. ... | Aortic regurgitation | step1 | C | Mitral stenosis | Mitral regurgitation | Aortic regurgitation | Aortic stenosis
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A 54-year-old woman comes to the physician because of a painful skin lesion on her right leg for 1 month. It initially started out as a small red spot but has rapidly increased in size during this period. She remembers an ant bite on her leg prior to the lesion occurring. She was treated for anterior uveitis 8 months a... | Pyoderma gangrenosum | step2&3 | B | Ecthyma gangrenosum | Pyoderma gangrenosum | Blastomycosis | Basal cell carcinoma
" | en |
A primary care physician is recently receiving more negative online reviews from his patients. He is increasingly feeling tired and has written 2 wrong prescriptions over the past month alone. Currently, on his panel, he has a list of 1,051 patients, half of whom are geriatric patients. He spends approx. 51 hours per w... | Excessive bureaucratic tasks | step2&3 | B | The number of patients on his panel | Excessive bureaucratic tasks | Working too many hours | Concern over online reputation | en |
A 42-year-old Caucasian woman is enrolled in a randomized controlled trial to study cardiac function in the setting of several different drugs. She is started on verapamil and instructed to exercise at 50% of her VO2 max while several cardiac parameters are being measured. During this experiment, which of the following... | Purkinje fibers > atria > ventricles > AV node | step2&3 | C | Atria > Purkinje fibers > ventricles > AV node | AV node > ventricles > atria > Purkinje fibers | Purkinje fibers > atria > ventricles > AV node | Purkinje fibers > AV node > ventricles > atria | en |
A 7-year-old boy comes to the physician because of a generalized rash for 3 days. Over the past 5 days, he has also had a high fever and a sore throat. His 16-year-old sister was treated for infectious mononucleosis 2 weeks ago. He returned from a summer camp a week ago. His immunizations are up-to-date. Three years ag... | Azithromycin therapy | step2&3 | C | Acyclovir therapy | Amoxicillin therapy | Azithromycin therapy | Cephalexin therapy | en |
A 30-year-old woman comes to the physician because of a swelling on her neck for 5 months. It has gradually enlarged in size and is mildly painful. She has also had intermittent episodes of throbbing headache, sweating, and palpitations over the past 3 months. Menses occur at regular 28-day intervals and last for 4–5 d... | Increased plasma metanephrines | step2&3 | D | Increased serum gastrin | Increased serum cortisol | Increased serum T3 levels | Increased plasma metanephrines | en |
A 31-year-old G3P1 woman who is at 37 weeks of gestation is brought into the emergency department by her husband after repeated twitching. According to the husband, they were watching TV when she suddenly became unresponsive and her hands and legs started shaking. The episode lasted about 5 minutes and she “seemed to b... | Intravenous magnesium sulfate | step1 | D | Emergency cesarean section | Expectant management | Intravenous infusion of oxytocin | Intravenous magnesium sulfate | en |
A 65-year-old man was picked up by the security personnel for voiding urine and defecating at an inappropriate place in the community. On questioning, he was making offensive remarks and behaving inappropriately. On physical examination, the physician observed an ataxic gait and amnesia. Initial urine drug screen is ne... | Pick bodies | step1 | C | Drug abuse | Lewy bodies | Pick bodies | Amyloid plaques | en |
A 52-year-old man undergoes an exercise stress test for a 1-week history of squeezing substernal chest pain that is aggravated by exercise and relieved by rest. During the test, there is a substantial increase in the breakdown of glycogen in the muscle cells. Which of the following changes best explains this intracellu... | Activation of phosphorylase kinase | step1 | B | Decrease in protein kinase A | Activation of phosphorylase kinase | Increase in glucose-6-phosphate | Inactivation of glycogen synthase kinase | en |
A 35-year-old man presents to the general practitioner with a skin rash that has been present for 2 days. The rash appeared suddenly and has progressively gotten worse. It started off as an erythematous lesion on the back of his hands and also over his nose. The lesions over his hands have become bullous and tense. He ... | Uroporphyrinogen III | step1 | A | Uroporphyrinogen III | Hydroxymethylbilane | Porphobilinogen | δ-Aminolevulinic acid | en |
A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. ... | Uterine rupture | step2&3 | C | Abruptio placentae | Vasa previa | Uterine rupture | Uterine inertia | en |
A 5-year-old boy is brought to the emergency department by his parents for difficulty breathing. He was playing outside in the snow and had progressive onset of wheezing and gasping. His history is notable for eczema and nut allergies. The patient has respirations of 22/min and is leaning forward with his hands on his ... | Cyclic AMP | step1 | B | Cyclic GMP | Cyclic AMP | Protein kinase C | ATP | en |
A 78-year-old male with history of coronary artery disease, status post coronary stent placement currently on aspirin and clopidogrel was found down in his bathroom by his wife. His GCS score was 3 and an accurate physical exam is limited. A stat non-contrast CT scan of his brain demonstrated a large right parietal int... | Low, Low, High, High | step2&3 | C | Low, High, High, High | Low, Low, High, Low | Low, Low, High, High | High, Low, Low, High | en |
A 53-year-old woman comes to the physician for a follow-up examination. One month ago, she was diagnosed with carcinoma of the left breast. She underwent a lumpectomy for a 2.1-cm mass and sentinel lymph node biopsy 2 weeks ago. The biopsy of the breast mass showed margin-free invasive ductal carcinoma; immunohistochem... | Echocardiography | step2&3 | A | Echocardiography | Fundoscopy | X-ray of the chest | Endometrial biopsy | en |
Three weeks after birth, an infant girl develops episodes of apnea. She has become increasingly lethargic over the past two days, and experienced two episodes of apnea lasting 10 seconds each within the last day. She was born at 31 weeks of gestation and weighed 1600-g (3-lb 8-oz). Apgar scores were 4 and 7 at 1 and 5 ... | Impaired erythropoietin production | step2&3 | D | Defective δ-aminolevulinic acid synthase | Bone marrow suppression | Glucose-6-phosphate dehydrogenase deficiency | Impaired erythropoietin production | en |
A 45-year-old woman presents to the physician with a 6-month history of progressive shortness of breath. She now has to stop to rest three or four times whenever she climbs the stairs to her apartment on the third floor. She reports chronic, nonproductive cough and wheezing, for which she uses ipratropium inhalers. She... | Decreased diffusing capacity of the lungs for carbon monoxide (DLCO) | step1 | B | Decreased lung residual volume | Decreased diffusing capacity of the lungs for carbon monoxide (DLCO) | Shift of the flow volume loop to the right | Decreased lung compliance | en |
A 27-year-old man is brought to a psychiatrist by his mother who is concerned that he has become increasingly distant. When asked, he says that he is no longer going out because he is afraid of going outside by himself. He says that ever since he was a teenager, he was uncomfortable in large crowds and on public transp... | Dependent | step1 | B | Antisocial | Dependent | Histrionic | Schizotypal | en |
A 26-year-old woman presents with sudden-onset pain in her lower back. She says she was exercising in the gym several hours ago when she felt a sharp pain. The pain is radiating down the side of her leg and into her foot. On physical exam, her vital signs are as follows: HR 95, BP 120/70, T 37.2 degrees C. She has extr... | Disc herniation | step2&3 | A | Disc herniation | Osteomyelitis | Spinal stenosis | Ankylosing spondylitis | en |
A 34-year-old man with AIDS comes to the physician because of a 2-day history of decreasing vision and seeing black spots in his right eye. He has no pain and the left eye is asymptomatic. He was treated for fungal esophagitis 6 months ago with fluconazole. He was diagnosed with Kaposi's sarcoma 2 years ago. Current me... | Cytomegalovirus retinitis | step2&3 | A | Cytomegalovirus retinitis | Toxoplasma retinitis | HIV retinopathy | Varicella zoster retinitis | en |
A 45-year old man comes to the physician because of a painless neck lump and a 2-month history of difficulty swallowing. He has a history of recurrent nephrolithiasis and episodic hypertension. Physical examination shows a 3 × 3-cm, nontender nodule at the level of the thyroid cartilage. A photomicrograph of a section ... | Medullary carcinoma | step1 | D | Follicular carcinoma | Non-Hodgkin lymphoma | Papillary carcinoma | Medullary carcinoma | en |
A 17-year-old boy is brought to the physician because of increasing pain and swelling of his right knee for 12 days. He has had episodes of pain with urination for 3 weeks. He had a painful, swollen left ankle joint that resolved without treatment one week ago. His mother has rheumatoid arthritis. He is sexually active... | Reactive arthritis | step2&3 | C | Septic arthritis | Lyme arthritis | Reactive arthritis | Syphilitic arthritis
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