question stringlengths 66 3.58k | answer stringlengths 1 230 | options dict | meta_info stringclasses 2
values | answer_idx stringclasses 4
values | metamap_phrases listlengths 1 184 |
|---|---|---|---|---|---|
A 38-year-old man comes to the physician because of a 3-week history of a painful rash affecting his left foot. For the past 2 years, he has had recurrent episodes of color changes in his fingers when exposed to the cold; his fingers first turn white and then progress to blue and red before spontaneously resolving. He ... | Segmental thrombosing inflammation with sparing of the internal elastic lamina | {
"A": "Granulomatous inflammation with narrowing of the vessel lumen",
"B": "Segmental thrombosing inflammation with sparing of the internal elastic lamina",
"C": "Calcification of the tunica media with foam cells and fibrous cap formation",
"D": "Transmural inflammation with fibrinoid necrosis of the vessel w... | step1 | B | [
"year old man",
"physician",
"3 week history",
"painful rash affecting",
"left foot",
"past",
"years",
"recurrent episodes of color changes",
"fingers",
"exposed",
"cold",
"fingers first turn white",
"then progress",
"blue",
"red",
"resolving",
"smoked two packs",
"cigarettes daily... |
A 35-year-old male nurse presents to the emergency room complaining of fever and malaise. He recently returned from a medical trip to Liberia to help with a deadly outbreak of a highly infectious disease. He reports severe generalized muscle pain, malaise, fatigue, and a sore throat. He has recently developed some diff... | Marburg virus | {
"A": "Dengue virus",
"B": "Lassa fever virus",
"C": "Hantavirus",
"D": "Marburg virus"
} | step1 | D | [
"35 year old male nurse presents",
"emergency room",
"fever",
"malaise",
"recently returned",
"medical trip",
"Liberia to help",
"outbreak",
"highly infectious disease",
"reports severe generalized muscle",
"malaise",
"fatigue",
"sore throat",
"recently",
"difficulty breathing",
"nonpr... |
A 56-year-old woman presents to the physician for a routine health maintenance examination. She has no history of a serious illness and takes no medications. She exercises every day and follows a healthy diet. She does not smoke and consumes alcohol moderately. There is no family history of chronic disease. Her blood p... | Atorvastatin | {
"A": "Atorvastatin",
"B": "Evolocumab",
"C": "Ezetimibe",
"D": "No pharmacotherapy at this time"
} | step2&3 | A | [
"year old woman presents",
"physician",
"routine health maintenance examination",
"history",
"serious illness",
"takes",
"medications",
"exercises",
"day",
"follows",
"healthy diet",
"not smoke",
"alcohol moderately",
"family history of chronic disease",
"blood pressure",
"mm Hg",
"c... |
A 2-year-old boy is brought to the physician because of progressive difficulty breathing and a productive cough for the past 2 days. During the past 6 months, he has had recurrent episodes of pneumonia treated with antibiotics. He has not gained weight in this time period. His temperature is 38.5°C (101.3°F), pulse is ... | Overexpression of the N-myc oncogene | {
"A": "Overexpression of the N-myc oncogene",
"B": "Increased lymphoblast count in the bone marrow",
"C": "Unregulated B-cell proliferation in the mediastinum",
"D": "Acid-fast bacteria on sputum microscopy"
} | step2&3 | A | [
"2 year old boy",
"brought",
"physician",
"progressive difficulty breathing",
"productive cough",
"past 2 days",
"past 6 months",
"recurrent episodes of pneumonia treated with antibiotics",
"not gained weight",
"time period",
"temperature",
"pulse",
"min",
"respirations",
"min",
"blood... |
A 62-year-old man presents to the physician because of difficulty initiating urination, terminal dribbling of urine, and bone pain for 3 months. He has no medical history of serious illness, and he currently takes no medications. His father had prostate cancer at age 58. His vital signs are within normal limits. The ph... | Androgen deprivation therapy | {
"A": "Active surveillance",
"B": "Androgen deprivation therapy",
"C": "Chemotherapy",
"D": "Radical prostatectomy"
} | step2&3 | B | [
"62 year old man presents",
"physician",
"difficulty initiating urination",
"terminal dribbling of urine",
"bone pain",
"months",
"medical history of serious illness",
"currently takes",
"medications",
"father",
"prostate cancer",
"age 58",
"vital signs",
"normal limits",
"physical exami... |
A 53-year-old woman presents to a medical clinic complaining of diarrhea. She also has episodes during which her face becomes red and she becomes short of breath. These symptoms have been ongoing for the past few months. Five years ago she had an appendectomy. The medical history is otherwise not significant. On physic... | Start the patient on octreotide to manage the symptoms | {
"A": "Explain to the patient that this condition would resolve spontaneously",
"B": "Start the patient on octreotide to manage the symptoms",
"C": "Start the patient on propranolol",
"D": "Perform a liver nodule excision with wide margins"
} | step1 | B | [
"year old woman presents",
"medical",
"diarrhea",
"episodes",
"face",
"red",
"short of breath",
"symptoms",
"ongoing",
"past",
"months",
"Five years",
"appendectomy",
"medical history",
"not significant",
"physical examination",
"vital signs",
"normal",
"Wheezing",
"heard",
"... |
A 23-year-old woman presents to a medical clinic for a follow-up visit. She initially came with complaints of recurrent headaches and darkening of her knuckles and skin creases, which first began 6 months ago after she underwent bilateral adrenalectomy. Today, she says that she frequently bumps into people and objects ... | Loss of a regulatory process | {
"A": "Ectopic secretion of a trophic hormone",
"B": "Hormonal receptor downregulation",
"C": "Loss of a regulatory process",
"D": "Feedback inhibition by an exogenous source"
} | step1 | C | [
"23 year old woman presents",
"medical clinic",
"follow-up visit",
"initially",
"complaints",
"recurrent headaches",
"knuckles",
"skin creases",
"first began",
"months",
"bilateral adrenalectomy",
"Today",
"frequently",
"people",
"objects",
"walking",
"following mechanisms",
"likel... |
A 6-year-old boy is brought in by his mother for a well-visit. She reports that he is going to start kindergarten soon. She is worried that he doesn’t like to play outside with the other kids on the block. When asked, the patient says “I like video games more than running. My big brother plays with me.” His mother stat... | Reassurance | {
"A": "Chest radiograph",
"B": "Echocardiogram",
"C": "Electrocardiogram",
"D": "Reassurance"
} | step2&3 | D | [
"year old boy",
"brought",
"mother",
"well visit",
"reports",
"to start kindergarten",
"worried",
"to play outside",
"kids",
"block",
"patient",
"I",
"video games",
"running",
"big brother plays",
"mother states",
"teachers reported",
"well",
"pre-school",
"group games",
"pat... |
A 9-year-old boy with cerebral palsy is about to undergo a femoral osteotomy. An intravenous catheter needs to be placed; however, given prior experience the boy is extremely anxious and does not want to be stuck with a needle while awake. The decision is made to administer appropriate anesthesia by mask first before a... | Low blood solubility | {
"A": "High cerebrospinal fluid solubility",
"B": "High lipid solubility",
"C": "Low blood solubility",
"D": "Low lipid solubility"
} | step1 | C | [
"year old boy",
"cerebral palsy",
"to",
"femoral osteotomy",
"intravenous catheter needs to",
"placed",
"given prior experience",
"boy",
"extremely anxious",
"not",
"to",
"stuck",
"needle",
"awake",
"decision",
"made to administer appropriate anesthesia",
"mask first",
"procedures"... |
A 63-year-old woman presents to her physician with hip pain. She has had pain in both hips for almost 5 years, and it has progressed over time. She notes that it gets worse as the day goes on, making it difficult for her to walk her small dog in the evening. She has a little morning stiffness which subsides quickly aft... | Switching acetaminophen to meloxicam | {
"A": "Switching acetaminophen to meloxicam",
"B": "Switching acetaminophen to oral methylprednisolone",
"C": "Addition of glucosamine supplementation",
"D": "Increasing the dose of acetaminophen to 6000 mg per day"
} | step2&3 | A | [
"63 year old woman presents",
"physician",
"hip pain",
"pain in",
"hips",
"almost",
"years",
"progressed",
"time",
"notes",
"gets worse",
"day goes",
"making",
"difficult",
"to walk",
"small dog",
"evening",
"little morning stiffness",
"starts to walk",
"last week",
"pain",
... |
A 33-year-old man comes into the ED after getting into a fight at a bar. He tells the physician that he was punched in the face for no reason. In the ED, he declares multiple times that he is incredibly angry and upset that he was beaten up. The patient's mood rapidly shifts between anger and sadness. He is wearing a m... | Histrionic personality disorder | {
"A": "Borderline personality disorder",
"B": "Histrionic personality disorder",
"C": "Narcisstic personality disorder",
"D": "Schizotypal personality disorder"
} | step1 | B | [
"year old man",
"ED",
"getting",
"fight",
"bar",
"physician",
"punched",
"face",
"reason",
"ED",
"multiple times",
"angry",
"upset",
"patient's mood rapidly shifts",
"anger",
"sadness",
"multi colored top",
"bright yellow pants",
"makes broad gestures",
"speaking",
"paramedic... |
A 33-year-old African American woman presents to the clinic complaining of pain and swelling of her hands and wrists for the past 5 months. The symptoms are worse in the morning and are associated with stiffness that lasts about 15 minutes. She also complains of profound fatigue and decreased appetite. She is sexually ... | Systemic lupus erythematosus | {
"A": "Parvovirus B19 infection",
"B": "Systemic lupus erythematosus",
"C": "Behcet disease",
"D": "Disseminated gonococcal arthritis"
} | step2&3 | B | [
"year old African American woman presents",
"clinic",
"pain",
"swelling of",
"hands",
"wrists",
"past",
"months",
"symptoms",
"worse",
"morning",
"associated with stiffness",
"lasts",
"15 minutes",
"profound fatigue",
"decreased appetite",
"sexually active",
"one partner",
"monog... |
A 44-year-old man presents to urgent care with severe vomiting. He states that he was at a camping ground for a party several hours ago and then suddenly began vomiting profusely. He denies experiencing any diarrhea and otherwise states he feels well. The patient only has a past medical history of lactose intolerance a... | Egg salad | {
"A": "Egg salad",
"B": "Fish",
"C": "Home-made ice cream",
"D": "Refried rice"
} | step2&3 | A | [
"year old man presents",
"urgent care",
"severe vomiting",
"states",
"camping",
"party",
"hours",
"then",
"began vomiting",
"denies experiencing",
"diarrhea",
"states",
"feels well",
"patient only",
"past medical lactose intolerance",
"hypertension managed",
"exercise",
"low salt d... |
A 52-year-old man comes to the physician for a follow-up examination 1 year after an uncomplicated liver transplantation. He feels well but wants to know how long he can expect his donor graft to function. The physician informs him that the odds of graft survival are 90% at 1 year, 78% at 5 years, and 64% at 10 years. ... | 71% | {
"A": "64%",
"B": "82%",
"C": "71%",
"D": "58%"
} | step1 | C | [
"year old man",
"physician",
"follow-up examination 1 year",
"uncomplicated liver transplantation",
"feels well",
"to",
"long",
"donor graft to function",
"physician informs",
"graft survival",
"90",
"year",
"years",
"64",
"10 years",
"time",
"probability",
"patient's graft survivi... |
A 42-year-old man who recently immigrated from Mexico presents to the clinic with fever, a productive cough streaked with blood, back pain, and night sweats. He was found to be HIV-positive 3 years ago but does not know his most recent CD4+ count. With further questioning, the patient notes that he had previously exper... | Epithelioid cells surrounded by multinucleated giant cells and lymphocytes | {
"A": "Cellular debris and macrophages followed by cystic spaces and cavitation",
"B": "Epithelioid cells surrounded by multinucleated giant cells and lymphocytes",
"C": "Macrophage filled with fungal microorganisms",
"D": "Noncaseating granuloma"
} | step1 | B | [
"year old man",
"recently",
"Mexico presents",
"clinic",
"fever",
"productive cough streaked",
"blood",
"back pain",
"night sweats",
"found to",
"HIV positive 3 years",
"not",
"most recent CD4",
"count",
"further questioning",
"patient notes",
"experienced",
"symptoms",
"Mexico",... |
An 87-year-old woman presents with fever, fatigue, and blood in her urine. She says that symptoms onset 3 days ago and have not improved. She describes the fatigue as severe and that her urine also has an odd smell to it. She denies any recent history of chills, abdominal or flank pain, or similar past symptoms. Past m... | Interferon-gamma release assays | {
"A": "Chest X-ray",
"B": "Sputum culture",
"C": "Culture in Löwenstein-Jensen media",
"D": "Interferon-gamma release assays"
} | step1 | D | [
"87 year old woman presents",
"fever",
"fatigue",
"blood in",
"urine",
"symptoms onset",
"days",
"not improved",
"fatigue",
"severe",
"urine",
"odd smell",
"denies",
"recent history",
"chills",
"abdominal",
"flank pain",
"similar past symptoms",
"medical history",
"significant"... |
A 3-year-old girl is brought to the emergency room because of a 5-day history of high fever and fatigue. During this time she has been crying more than usual and eating less. Her mother says that the child has also complained about pain in her arms and legs for the past 3 days. She was born at term and has been otherwi... | Obtain 3 sets of blood cultures | {
"A": "Administer intravenous vancomycin",
"B": "Measure rheumatoid factors",
"C": "Obtain 3 sets of blood cultures",
"D": "Obtain a transesophageal echocardiography"
} | step2&3 | C | [
"3 year old girl",
"brought",
"emergency room",
"5-day history",
"high fever",
"fatigue",
"time",
"crying more",
"usual",
"eating",
"mother",
"child",
"pain",
"arms",
"legs",
"past 3 days",
"born",
"term",
"healthy",
"appears ill",
"temperature",
"pulse",
"min",
"blood ... |
A 30-year-old primigravid woman at 16 weeks' gestation comes to the emergency department because of vaginal bleeding. She has had spotting for the last 2 days. She has had standard prenatal care. A viable uterine pregnancy was confirmed on ultrasonography during a prenatal care visit 2 weeks ago. She reports recurrent ... | Placental thrombosis | {
"A": "Chromosomal abnormalities",
"B": "Subchorionic hematoma",
"C": "Hyperfibrinolysis",
"D": "Placental thrombosis"
} | step2&3 | D | [
"30 year old primigravid woman",
"weeks",
"estation ",
"mergency department ",
"aginal bleeding.",
"potting ",
" days.",
"tandard renatal care.",
"iable terine regnancy ",
"onfirmed ",
"ltrasonography ",
"renatal isit ",
"eeks ",
"eports ecurrent pisodes of ain ",
"ight wrist ",
... |
A 45-year-old man presents to his primary care physician for a general checkup. The patient has no complaints, but is overweight by 20 lbs. The physician orders outpatient labs which come back with an elevated total bilirubin. Concerned, the PCP orders further labs which show: total bilirubin: 2.4, direct bilirubin 0.6... | Diagnosis is readily made with characteristic metabolic response to rifampin | {
"A": "Treatment is centered around decreasing total body iron with chelation and serial phlebotomy",
"B": "Laparoscopy would demonstrate a blackened liver due to buildup of metabolites",
"C": "This patient's disease exhibits autosomal recessive inheritance, with complete penetrance",
"D": "Diagnosis is readil... | step1 | D | [
"year old man presents",
"primary care physician",
"general checkup",
"patient",
"complaints",
"overweight",
"20 lbs",
"physician orders outpatient labs",
"back",
"elevated total bilirubin",
"Concerned",
"PCP orders further labs",
"show",
"total bilirubin",
"2.4",
"direct bilirubin 0.6... |
A clinical trial is conducted to determine the role of cerebrospinal fluid (CSF) beta-amyloid levels as a biomarker in the early detection and prognosis of Alzheimer disease. A total of 100 participants are enrolled and separated into three groups according to their Mini-Mental State Examination (MMSE) score: mild deme... | Analysis of variance | {
"A": "Chi-square test",
"B": "Two-sample t-test",
"C": "Pearson correlation analysis",
"D": "Analysis of variance"
} | step1 | D | [
"clinical trial",
"conducted to",
"role",
"cerebrospinal fluid",
"beta-amyloid levels",
"biomarker",
"early detection",
"prognosis",
"Alzheimer disease",
"total",
"100 participants",
"enrolled",
"separated",
"three groups",
"Mini-Mental State Examination",
"score",
"mild dementia",
... |
A 58-year-old woman with a history of rheumatic fever has been experiencing exertional fatigue and dyspnea. She has begun using several pillows at night to sleep and occasionally wakes up at night gasping for air. On exam, she appears dyspneic and thin. Cardiac exam reveals a loud S1, opening snap, and apical diastolic... | Short time between A2 and the opening snap | {
"A": "Greater intensity of the diastolic rumble",
"B": "Short time between A2 and the opening snap",
"C": "Shorter duration of the diastolic rumble",
"D": "Presence of rales"
} | step1 | B | [
"58 year old woman",
"history of rheumatic fever",
"experiencing exertional fatigue",
"dyspnea",
"begun using several pillows",
"night to sleep",
"occasionally wakes up",
"night gasping for air",
"exam",
"appears dyspneic",
"thin",
"Cardiac exam reveals",
"loud S1",
"opening snap",
"apic... |
A 48-year-old man comes to the physician because of a 1-month history of a productive cough. He has daily yellowish sputum with occasional streaks of blood in it. Twelve years ago, he was treated for pulmonary tuberculosis for 6 months. He has hypertension and coronary artery disease. He does not smoke or drink alcohol... | Repositioning the patient causes the mass to move | {
"A": "Repositioning the patient causes the mass to move",
"B": "Clusters of gram-positive cocci in sputum",
"C": "Multiple lytic foci on skeletal scintigraphy",
"D": "Positive c-ANCA test\n\""
} | step2&3 | A | [
"48 year old man",
"physician",
"1-month history",
"productive cough",
"daily",
"sputum",
"occasional streaks",
"blood",
"Twelve years",
"treated",
"pulmonary",
"months",
"hypertension",
"coronary artery disease",
"not smoke",
"drink alcohol",
"Current medications include metoprolol"... |
A 73-year-old woman is brought to the physician by her son because of a 2-month history of diarrhea and recurrent upper respiratory tract infections. Her son says that she frequently trips over the nightstand when she gets up to go to the bathroom at night. She is 173 cm (5 ft 8 in) tall and weighs 54 kg (120 lb); BMI ... | Retinol | {
"A": "Retinol",
"B": "Zinc",
"C": "Riboflavin",
"D": "Niacin"
} | step1 | A | [
"year old woman",
"brought",
"physician",
"son",
"month history",
"diarrhea",
"recurrent upper respiratory tract infections",
"son",
"frequently trips",
"gets",
"go",
"bathroom",
"night",
"5 ft 8",
"tall",
"54 kg",
"BMI",
"kg/m2",
"Physical examination shows dry skin",
"multipl... |
An 11-year-old boy is brought to the emergency department by his parents for confusion and fever. The patient began complaining of a headache yesterday afternoon that progressively got worse. After waking him up this morning, his mom noticed that “he seemed funny and wasn’t able to carry a conversation fully.” When ask... | Optochin sensitivity | {
"A": "Culture on chocolate agar with factors V and X",
"B": "K-capsule",
"C": "Optochin sensitivity",
"D": "Pyocyanin production"
} | step1 | C | [
"year old boy",
"brought",
"emergency department",
"parents",
"confusion",
"fever",
"patient began complaining of a headache",
"afternoon",
"got worse",
"waking",
"morning",
"mom",
"able to carry",
"conversation",
"past medical history",
"dad",
"healthy",
"3 episodes of finger pain... |
A 40-year-old man is bitten by a copperhead snake, and he is successfully treated with sheep hyperimmune Fab antivenom. Six days later, the patient develops an itchy abdominal rash and re-presents to the emergency department for medical care. He works as a park ranger. His medical history is significant for gout, hyper... | Type III–immune complex-mediated hypersensitivity reaction | {
"A": "Type I–anaphylactic hypersensitivity reaction",
"B": "Type II–cytotoxic hypersensitivity reaction",
"C": "Type III–immune complex-mediated hypersensitivity reaction",
"D": "Type IV–cell-mediated (delayed) hypersensitivity reaction"
} | step2&3 | C | [
"40 year old man",
"bitten",
"copperhead snake",
"treated with sheep",
"antivenom",
"Six days later",
"patient",
"itchy abdominal",
"re presents",
"emergency department",
"medical care",
"works",
"park",
"medical history",
"significant",
"gout",
"hypertension",
"hypercholesterolemi... |
Treatment with intravenous acyclovir is initiated. Three days later, the patient develops progressively worse fatigue, headache, and colicky pain in his right flank. His temperature is 36.7°C (98°F), pulse is 85/min, and blood pressure is 135/80 mm Hg. Examination shows no new lesions. Laboratory studies show:
Hemoglob... | Crystals and white blood cells | {
"A": "Eosinophils and red blood cells",
"B": "Gram-negative rods and white blood cell casts",
"C": "Crystals and white blood cells",
"D": "Fatty casts and proteinuria"
} | step2&3 | C | [
"Treatment",
"intravenous acyclovir",
"initiated",
"Three days later",
"patient",
"worse fatigue",
"headache",
"colicky pain",
"right flank",
"temperature",
"36",
"pulse",
"85 min",
"blood pressure",
"80 mm Hg",
"Examination shows",
"new lesions",
"Laboratory studies show",
"Hemo... |
A 16-year-old boy is brought to the physician by his parents because of a 6-month history of progressive fatigue and worsening shortness of breath on exertion. The parents report that the boy “has always been tired out a bit more easily than other kids.” The family recently immigrated to the United States from rural So... | Persistent blood flow between the pulmonary artery and descending aorta | {
"A": "Single overriding great vessel arising from the heart",
"B": "Persistent blood flow between the pulmonary artery and descending aorta",
"C": "Positioning of the ascending aorta directly over a ventricular septal defect",
"D": "Abnormal narrowing of the aorta at the aortic isthmus"
} | step1 | B | [
"year old boy",
"brought",
"physician",
"parents",
"month history",
"progressive fatigue",
"worsening shortness of breath",
"exertion",
"parents report",
"boy",
"always",
"tired out",
"bit",
"easily",
"kids",
"family recently",
"United States",
"rural South Korea",
"Pulse oximetr... |
A 69-year-old woman is brought to the emergency department by her husband for evaluation of the sudden onset of chest pain and breathlessness 2 hours ago. The pain increases with deep inspiration. She had a total hip replacement 20 days ago. She has hypertension, for which she takes a calcium channel blocker. She has s... | Embolism | {
"A": "Thrombosis",
"B": "Embolism",
"C": "Pulmonary atherosclerosis",
"D": "Arteriosclerosis"
} | step1 | B | [
"69 year old woman",
"brought",
"emergency department",
"husband",
"evaluation",
"sudden onset",
"chest pain",
"breathlessness",
"hours",
"pain increases",
"deep inspiration",
"total hip replacement 20 days",
"hypertension",
"takes",
"calcium channel blocker",
"smoked 1 pack",
"cigar... |
A 10-year-old boy comes to the physician for a follow-up examination. He was diagnosed with asthma one year ago and uses an albuterol inhaler as needed. His mother reports that he has had shortness of breath on exertion and a dry cough 3–4 times per week over the past month. Pulmonary examination shows expiratory wheez... | Oral rinsing after medication administration | {
"A": "Pantoprazole use prior to meals",
"B": "Minimizing use of a spacer",
"C": "Oral rinsing after medication administration",
"D": "Weight-bearing exercise three times weekly"
} | step1 | C | [
"A 10 year old boy",
"physician",
"follow-up examination",
"diagnosed",
"asthma one year ago",
"uses",
"albuterol inhaler as needed",
"mother reports",
"shortness of breath",
"exertion",
"dry cough",
"times",
"week",
"past month",
"Pulmonary examination shows expiratory wheezing",
"lun... |
A 20-year-old woman with no significant past medical history presents to the urgent care clinic with increased vaginal discharge and dysuria. On social history review, she endorses having multiple recent sexual partners. The patient uses oral contraceptive pills for contraception and states that she has not missed a pi... | Single-dose PO metronidazole | {
"A": "Single-dose PO metronidazole",
"B": "Vaginal metronidazole",
"C": "PO fluconazole",
"D": "IM benzathine penicillin"
} | step2&3 | A | [
"20 year old woman",
"significant past medical history presents",
"urgent care clinic",
"increased vaginal discharge",
"dysuria",
"social history review",
"multiple recent sexual partners",
"patient uses oral contraceptive pills",
"contraception",
"states",
"not missed",
"pill",
"patient's b... |
A 2-year-old girl presented to the emergency department after a generalized tonic-clonic seizure that lasted one minute, an hour ago. She has been in good health since birth and has no history of convulsions in the past. She has been sick with an upper respiratory tract infection for the last 2 days, and her parents ha... | Glutathione saturation | {
"A": "Hemosiderin deposition",
"B": "Ca2+ efflux",
"C": "Glutathione saturation",
"D": "Decrease in hypothalamic set point"
} | step1 | C | [
"2 year old girl presented",
"emergency department",
"generalized tonic-clonic seizure",
"lasted one minute",
"hour",
"good health",
"birth",
"history",
"convulsions",
"past",
"sick",
"upper respiratory tract infection",
"last 2 days",
"parents",
"at home",
"subjective fever",
"blood... |
A 37-year-old man comes to the emergency department with his wife because of a 3-day history of severe pain in his right arm. He also reports that he cannot move his right arm. The symptoms began after the patient woke up one morning, having slept on his side. He is otherwise healthy. He works as a waiter and says that... | Malingering | {
"A": "Brachial neuritis",
"B": "Factitious disorder",
"C": "Malingering",
"D": "Radial nerve palsy"
} | step2&3 | C | [
"year old man",
"emergency department",
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"... |
A female newborn delivered at 38 weeks’ gestation is evaluated for abdominal distention and bilious vomiting 24 hours after delivery. The pregnancy and delivery were uncomplicated. She appears lethargic and her fontanelles are sunken. An x-ray of the abdomen is shown. This infant most likely has a congenital obstructio... | Duodenum
" | {
"A": "Esophagus",
"B": "Ileum",
"C": "Pylorus",
"D": "Duodenum\n\""
} | step1 | D | [
"female newborn delivered",
"weeks gestation",
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"fontanelles",
"x-ray of",
"abdomen",
"shown",
"infant",
"likely",
"congenital obstruction affec... |
A group of researchers recently conducted a meta-analysis of twenty clinical trials encompassing 10,000 women with estrogen receptor-positive breast cancer who were disease-free following adjuvant radiotherapy. After an observation period of 15 years, the relationship between tumor grade and distant recurrence of cance... | 550/2500 | {
"A": "500/5000",
"B": "550/2500",
"C": "2500/10000",
"D": "1950/8575"
} | step1 | B | [
"A group",
"researchers recently conducted",
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"twenty clinical trials",
"10",
"women",
"estrogen receptor-positive breast cancer",
"disease free following adjuvant radiotherapy",
"observation period of",
"years",
"relationship",
"tumor grade",
"distant recurrence",
"cancer"... |
Specificity for breast examination is traditionally rather high among community practitioners. A team of new researchers sets forth a goal to increase specificity in detection of breast cancer from the previously reported national average of 74%. Based on the following results, has the team achieved its goal?
Breast ca... | Yes, the team has achieved an increase in specificity of approximately 8%. | {
"A": "No, the research team’s results lead to nearly the same specificity as the previous national average.",
"B": "Yes, the team has achieved an increase in specificity of approximately 8%.",
"C": "It can not be determined, as the prevalence of breast cancer is not listed.",
"D": "It can not be determined, s... | step1 | B | [
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A 3-year-old boy is brought to the physician for evaluation of pallor and increasing lethargy for 3 days. Six days ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since resolved. The family returned from a road trip to Mexico 4-weeks ago. His temperature is 38.8°C (101.8°F), pulse is 128/min... | Microthrombi formation | {
"A": "Bacteremia",
"B": "IgA Immune complex-mediated vasculitis",
"C": "Microthrombi formation",
"D": "Infection with an RNA picornavirus"
} | step1 | C | [
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"since resolved",
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"weeks",
"temperature",
"pulse",
"min",
"respi... |
A 39-year-old woman comes to the physician for worsening fatigue and dyspnea for several months. She has not been seen by a physician in 10 years. She is also concerned about the appearance of her fingernails. A photograph of her hands is shown. Which of the following is the most likely underlying cause for the patient... | Idiopathic pulmonary fibrosis | {
"A": "Psoriatic arthritis",
"B": "Iron deficiency anemia",
"C": "Idiopathic pulmonary fibrosis",
"D": "Chronic obstructive pulmonary disease"
} | step1 | C | [
"year old woman",
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"10 years",
"concerned about",
"appearance",
"fingernails",
"photograph",
"hands",
"shown",
"following",
"most likely underlying cause",
"patient's nail findings"
] |
A 23-year-old woman comes to the physician for a routine health maintenance examination. She feels well. Menses have occured at regular 30-day intervals and last for 5 days with normal flow. She has a history of gonorrhea that was treated at 20 years of age. She has smoked one pack of cigarettes daily for 3 years. She ... | Colposcopy | {
"A": "Colposcopy",
"B": "Endometrial sampling",
"C": "Repeat cytology in 6 months",
"D": "Loop electrosurgical excision"
} | step2&3 | A | [
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"3 years",
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A 65-year-old man with a history of myocardial infarction is admitted to the hospital for treatment of atrial fibrillation with rapid ventricular response. He is 180 cm (5 ft 11 in) tall and weighs 80 kg (173 lb). He is given an intravenous bolus of 150 mg of amiodarone. After 20 minutes, the amiodarone plasma concentr... | 60 L | {
"A": "60 L",
"B": "10 L",
"C": "80 L",
"D": "150 L"
} | step1 | A | [
"65-year-old man",
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"20 minutes",
"amiodarone plasma concentration",
"2.5 mcg/mL",
... |
A 32-year-old man presents with a fever that has persisted for 3 days. He says that the fever was initially low at around 37.8°C (100.0°F), but, for the past 2 days, it has been around 38.9°C (102.0°F), regardless of his attempts to bring it down. He has also noticed some bumps on his neck. On further questioning, he m... | It binds to the 30S subunit and prevents the formation of the initiation complex | {
"A": "It binds to the 50S subunit and prevents translocation",
"B": "It binds to the 30S subunit and prevents amino acid incorporation",
"C": "It binds to the 50S subunit and prevents the formation of the peptide bond",
"D": "It binds to the 30S subunit and prevents the formation of the initiation complex"
} | step1 | D | [
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"initially low",
"100",
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"attempts to",
"neck",
"further questioning",
"recently out rabbit hunting",
"friends",
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"antibiotic",
"requested to follow-up",
"2 weeks",
"follow-up",
"patient",
"better",
... |
A 7-year-old boy is rushed to the emergency room after developing severe abdominal pain with nausea and vomiting for a day at a summer camp. He also has a bad cough and generalized muscle weakness. He was doing fine until these symptoms started on day 3 of his camp. Past medical history obtained from his parents on the... | Iatrogenic suppression of a trophic effect on the adrenal glands | {
"A": "Bilateral hemorrhagic necrosis of the adrenal glands",
"B": "Iatrogenic suppression of a trophic effect on the adrenal glands",
"C": "An extremely virulent form of Influenza",
"D": "Primary adrenal insufficiency"
} | step1 | B | [
"year old boy",
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"fine",
"symptoms started",
"day 3",
"camp",
"Past medical history obtained",
"parents",
"phone",
"significant",
"recurrent... |
A 5-day-old newborn is brought into the pediatrician by her parents for new-onset vaginal bleeding. This morning, when the patient’s father was changing her diaper he noticed blood and white vaginal discharge. The patient was born at 39 weeks to a G1P1 mother who has well-controlled type 1 diabetes. The pregnancy and t... | Maternal estrogen withdrawal | {
"A": "Congenital adrenal hyperplasia",
"B": "External trauma",
"C": "Genitourinary infection",
"D": "Maternal estrogen withdrawal"
} | step2&3 | D | [
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"weeks",
"G1P1 mother",
"well-controlled type 1 diabetes",
"pregnancy",
"vaginal deliv... |
Image A depicts the distribution of the lab value of interest in 250 patients. Given that this is not a normal (i.e. Gaussian) distribution, how many patients are contained in the portion highlighted blue? | 125 patients | {
"A": "125 patients",
"B": "140 patients",
"C": "250 patients",
"D": "Not enough information provided"
} | step1 | A | [
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An investigator develops a new drug that decreases the number of voltage-gated potassium channels in cardiac muscle cell membranes. Which of the following is the most likely effect of this drug on the myocardial action potential? | Delayed repolarization | {
"A": "Decreased resting membrane potential",
"B": "Delayed repolarization",
"C": "Delayed depolarization",
"D": "Accelerated repolarization"
} | step1 | B | [
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"cardiac muscle cell membranes",
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] |
A 47-year-old man comes to the physician for a routine health maintenance examination. He states that he has felt fatigued and dizzy on several occasions over the past week. He has back pain for which he takes ibuprofen. Digital rectal examination shows no abnormalities. Laboratory studies show a hemoglobin concentrati... | Kidney stones | {
"A": "Bacteremia",
"B": "Kidney stones",
"C": "NSAID use",
"D": "Multiple myeloma"
} | step1 | B | [
"year old man",
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"Laboratory studies show a hemoglobin concentration",
"g/dL",
"serum u... |
A 36-year-old woman presents to the emergency department with a 2-day history of conjunctivitis, sensitivity to bright light, and decreased visual acuity. She denies a history of ocular trauma. She wears contact lenses and thought that the contact lenses may be the cause of the symptoms, although she has always used pr... | Herpes simplex virus (HSV)-1 | {
"A": "Herpes simplex virus (HSV)-1 ",
"B": "Acanthamoeba",
"C": "Candida albicans",
"D": "Pseudomonas "
} | step1 | A | [
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"symptoms",
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"hygiene",
"Fluorescein... |
A 9-year-old boy presents with persistent epistaxis. The patient’s mother says that his nosebleed started suddenly 2 hours ago, and has not ceased after more than 20 minutes of applying pressure. She states that he has a history of nosebleeds since he was a toddler, but, in the past, they usually stopped after a few mi... | Factor IX deficiency | {
"A": "Factor IX deficiency",
"B": "Presence of a factor VIII inhibitor",
"C": "Vitamin K deficiency",
"D": "Proteinuria"
} | step2&3 | A | [
"year old boy presents",
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A 55-year-old man presents to his primary care physician for leg pain. The patient works as a mailman but states he has had difficulty completing his deliveries for the past month. He complains of a burning and tingling pain in his legs when he walks that goes away when he sits down and takes a break. The patient has a... | Ankle-brachial index | {
"A": "Ankle-brachial index",
"B": "Arteriography",
"C": "Aspirin",
"D": "Atorvastatin"
} | step2&3 | A | [
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"stable ang... |
A 56-year-old woman comes to the physician with a 6-month history of black spots in her vision. She has been unable to drive at night for the past 4 months. The patient has rheumatoid arthritis, type 2 diabetes mellitus, and depression. Her mother has glaucoma. She has never smoked. She drinks one or two glasses of hom... | Chloroquine retinopathy | {
"A": "Chloroquine retinopathy",
"B": "Diabetic retinopathy",
"C": "Angle-closure glaucoma",
"D": "Age-related macular degeneration"
} | step2&3 | A | [
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"moonshine",
"d... |
A 43-year-old woman is brought to the physician by her daughter because she has been intermittently crying for 6 hours and does not want to get out of bed. Her symptoms started after she was fired yesterday from her job of 20 years. She says she feels sad and does not understand what she will do with her life now. She ... | Normal stress reaction | {
"A": "Major depressive disorder",
"B": "Normal stress reaction",
"C": "Adjustment disorder",
"D": "Drug-related depression"
} | step2&3 | B | [
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"life now",
"uses",
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"exercise-induced asthma",
"recently sta... |
An 83-year-old bedbound man presents with a shallow open ulcer over his sacrum, with a red wound bed. Upon further examination, he also has areas of non-blanching redness on his lateral malleoli. Which of the following interventions would most likely have prevented his condition? | Frequent repositioning | {
"A": "Nutritional supplementation",
"B": "Topical antibiotics",
"C": "Anti-coagulants",
"D": "Frequent repositioning"
} | step2&3 | D | [
"83 year old bedbound man presents",
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"red wound bed",
"further examination",
"areas",
"non blanching redness",
"lateral malleoli",
"following interventions",
"most likely",
"prevented",
"condition"
] |
An infant boy is brought to the physician for a well-child examination. He was born at term and has been healthy since. He is beginning to crawl but can not yet walk or run. He feeds himself small foods and can bang 2 cubes together. He is just beginning to successfully use a pincer grasp. He has stranger anxiety. He i... | Says mama or dada | {
"A": "Enjoys peek-a-boo",
"B": "Follows one-step commands",
"C": "Knows 3–6 words",
"D": "Says mama or dada"
} | step2&3 | D | [
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"percentile",
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"weight",
"Physical examination shows",
"abno... |
An otherwise healthy 8-year-old girl is brought to the physician by her parents because of concern for growth retardation. Although she has always been short for her age, her classmates have begun teasing her for her height. She is at the 5th percentile for height and 25th percentile for weight. Physical examination sh... | Aortic stenosis | {
"A": "Intellectual disability",
"B": "Aortic stenosis",
"C": "Acute lymphoblastic leukemia",
"D": "Lens dislocation"
} | step1 | B | [
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"Physical examination shows",
"low posterior",
"increased s... |
A 32-year-old woman presents to the clinic for routine follow-up. She recently discovered that she is pregnant and is worried about taking medications throughout her pregnancy. She has a history of hypothyroidism and takes levothyroxine daily. Her vital signs are unremarkable. Her physical exam is consistent with the e... | Well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters. | {
"A": "Pregnant women will need to reduce the dose of levothyroxine to prevent congenital malformations.",
"B": "Animal studies have shown an adverse effect to the fetus, but there are no adequate and well-controlled studies in humans.",
"C": "Levothyroxine use in pregnancy is contraindicated, and its use should... | step2&3 | D | [
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"takes levothyroxine daily",
"vital signs",
"unremarkable",
"physical exam",
"consistent with",
"estimated",
"week ges... |
A 61-year-old female with a history of breast cancer currently on chemotherapy is brought by her husband to her oncologist for evaluation of a tremor. She reports that she developed a hand tremor approximately six months ago, prior to the start of her chemotherapy. The tremor is worse at rest and decreases with purpose... | Metoclopramide | {
"A": "Ondansetron",
"B": "Diphenhydramine",
"C": "Loperamide",
"D": "Metoclopramide"
} | step1 | D | [
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"significant ... |
A 64-year-old female with a long-standing history of poorly-controlled diabetes presents with 3 weeks of abnormal walking. She says that lately she has noticed that she keeps dragging the toes of her right foot while walking, and this has led to her stubbing her toes. Upon physical exam, you notice a right unilateral f... | Deep peroneal nerve | {
"A": "Superficial peroneal nerve",
"B": "Deep peroneal nerve",
"C": "Tibial nerve",
"D": "Sural nerve"
} | step1 | B | [
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"walking",
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"toes",
"physical exam",
"right unilateral foot drop",
"decreased sensation",
"first dorsal web space",
"walks... |
A 55-year-old man with type 2 diabetes mellitus comes to the physician because of a 4-day history of fever, chills, nausea, and abdominal pain. He does not use illicit drugs. His temperature is 39°C (102.2°F). Physical examination shows right upper quadrant tenderness. Ultrasonography of the abdomen shows a 6-cm solita... | Myeloperoxidase | {
"A": "Prodigiosin",
"B": "Myeloperoxidase",
"C": "Staphyloxanthin",
"D": "Biliverdin"
} | step1 | B | [
"55 year old man",
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"not use illicit drugs",
"temperature",
"Physical examination shows right upper quadrant tenderness",
"Ultrasonography of",
"abdomen shows",
"solitary",
"fluid fill... |
Multiple sclerosis is an autoimmune disease in which T-lymphocytes initiate an immune system response targeting the myelin sheaths of the central nervous system. What stage of T-lymphocyte development is the most likely to be defective in this disorder? | Negative selection | {
"A": "Positive selection",
"B": "Negative selection",
"C": "D-J rearrangement",
"D": "V-DJ rearrangement"
} | step1 | B | [
"Multiple sclerosis",
"autoimmune disease",
"T-lymphocytes initiate",
"immune response targeting",
"myelin sheaths",
"central",
"stage",
"T-lymphocyte development",
"most likely to",
"defective",
"disorder"
] |
A 46-year-old man comes to the physician for a follow-up evaluation one week after being discharged from the hospital for acute pancreatitis and alcohol withdrawal. He drinks 8 to 10 beers daily. When the physician asks him about his alcohol use, the patient says, “This is the second time in a year that I have experien... | Contemplation | {
"A": "Maintenance",
"B": "Precontemplation",
"C": "Action",
"D": "Contemplation"
} | step1 | D | [
"year old man",
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"patient",
"second time",
"year",
"I",
"experienced",
"severe belly pain",
"... |
A 40-year-old male in West Virgina presents to the emergency room complaining that his vision has deteriorated within the past several hours to the point that he can no longer see. He explains that some acquaintances sold him some homemade liquor and stated that it was pure as it burned with a "yellow flame." Which of ... | Ethanol | {
"A": "Methylene blue",
"B": "Ethanol",
"C": "Atropine",
"D": "Succimer"
} | step1 | B | [
"40 year old male",
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"hours",
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"stated",
"pure",
"burned",
"yellow flame",
"following",
"administered immediately",
"drinking",
"liquor",
"saved",
"v... |
A 40-year-old woman with HIV infection presents to the emergency department because of a 4-week history of progressively worsening fatigue and headache. On mental status examination, the patient is somnolent and oriented only to person. Her CD4+ lymphocyte count is 80/mm3 (N = 500). Analysis of this patient's cerebrosp... | Cranial neuropathy | {
"A": "Chancre",
"B": "Cranial neuropathy",
"C": "Focal neurologic deficits",
"D": "Pulmonary symptoms"
} | step2&3 | B | [
"40 year old woman",
"HIV infection presents",
"emergency department",
"4 week history",
"worsening fatigue",
"headache",
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"somnolent",
"oriented only",
"person",
"CD4",
"lymphocyte count",
"80 mm3",
"N",
"500",
"Analysis",
"patient's cerebrospinal fluid",
"sh... |
A 45-year-old man presents with 2 weeks of low-grade fever, malaise, night sweats, orthopnea, and shortness of breath. Past medical history is unremarkable. He reports a long-standing history of intravenous drug use for which he has been hospitalized a couple of times in the psychiatry ward. His vital signs upon admiss... | Blood culture | {
"A": "Procalcitonin",
"B": "B-type natriuretic peptide",
"C": "CPK-MB",
"D": "Blood culture"
} | step1 | D | [
"year old man presents",
"2 weeks",
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"malaise",
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"Past medical history",
"unremarkable",
"reports",
"long standing history of intravenous drug use",
"hospitalized",
"couple",
"times",
"psychiatry ward",
"vital signs",... |
A 60-year-old-man presents to his physician with worsening myalgias and new symptoms of early fatigue, muscle weakness, and drooping eyelids. His wife presents with him and states that he never used to have such symptoms. His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus... | Exclusion of a thymoma | {
"A": "Assessment for motor neuron disease",
"B": "Exclusion of underlying lung cancer",
"C": "Exclusion of a thymoma",
"D": "Evaluation of congenital vascular anomaly"
} | step2&3 | C | [
"60 year old man presents",
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"new symptoms",
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"drooping eyelids",
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"states",
"never used to",
"symptoms",
"medical history",
"significant",
"gout",
"hypertension",
"hypercholesterolemia",
"diabetes m... |
A 52-year-old man presents his primary care physician for follow-up. 3 months ago, he was diagnosed with type 2 diabetes mellitus and metformin was started. Today, his HbA1C is 7.9%. The physician decides to add pioglitazone for better control of hyperglycemia. Which of the following is a contraindication to pioglitazo... | History of bladder cancer | {
"A": "Renal impairment",
"B": "Genital mycotic infection",
"C": "Pancreatitis",
"D": "History of bladder cancer"
} | step2&3 | D | [
"year old man presents",
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"months",
"diagnosed",
"type 2 diabetes mellitus",
"metformin",
"started",
"Today",
"physician",
"to add pioglitazone",
"better control",
"hyperglycemia",
"following",
"contraindication",
"pioglitazone therapy"
] |
A 32-year-old woman comes in to see her physician because she has had undiagnosed abdominal pain for the past 3 and a half years. Her pain is not related to meals and does not correspond to a particular time of day, although she does report nausea and bloating. In the past two years she has had two endoscopies, a colon... | Somatic symptom disorder | {
"A": "Somatic symptom disorder",
"B": "Functional neurologic symptom disorder",
"C": "Hypochondriasis",
"D": "Factitious disorder"
} | step2&3 | A | [
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"pain",
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"report nausea",
"bloating",
"past two years",
"two endoscopies",
"colonoscopy",
"results",
"very concerned",
"mother",
"history cance... |
An 18-year-old man is hospitalized after a suicide attempt, his 6th such attempt in the last 4 years. He was diagnosed with depression 5 years ago, for which he takes fluoxetine. He is currently complaining of severe and worsening left knee swelling and pain since he attempted suicide by jumping out of his second-story... | Administer intravenous antibiotics and repeat arthrocentesis | {
"A": "Administer naproxen and oral antibiotics",
"B": "Administer intravenous antibiotics and repeat arthrocentesis",
"C": "Obtain a radiograph of the knee and administer indomethacin",
"D": "Administer naproxen and colchicine"
} | step2&3 | B | [
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"attempted suicide",
"jumping",
"second-story bedroom window",
"sustained minor injuries",
"time",
"lace... |
A 75-year-old man who underwent a bilateral lung transplant 11 months ago presented to the emergency room with fevers and chills. After the transplant procedure, he was immediately placed on immunosuppressive treatment; however, for unknown reasons he stopped taking the prophylactically-prescribed voriconazole (a triaz... | Coccidioides species | {
"A": "Coccidioides species",
"B": "Blastomyces dermatitidis",
"C": "Cryptococcus neoformans",
"D": "Histoplasma capsulatum"
} | step1 | A | [
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"immediately placed",
"immunosuppressive treatment",
"unknown reasons",
"stopped taking",
"prescribed voriconazole",
"triazole used",
"treatment",
"preve... |
A 53-year-old man presents to the urgent care clinic with a persistent cough and progressively worsening shortness of breath. He has had these symptoms for several weeks and used to only become breathless during exercise but now has breathing difficulty while at rest. The patient says that he has mild-to-moderate respi... | Cystic airspaces in the lung interstitium on CT scan | {
"A": "Cushing’s syndrome",
"B": "Acute exposure to asbestos",
"C": "Reversal of symptoms with smoking cessation",
"D": "Cystic airspaces in the lung interstitium on CT scan"
} | step2&3 | D | [
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"urgent care clinic",
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"weeks",
"used to only",
"breathless",
"exercise",
"now",
"breathing difficulty",
"rest",
"patient",
"mild-to-moderate respiratory distress",
"fatigue",
"months",
"Past med... |
A 17-year-old girl is brought to the physician by her parents for the evaluation of belly pain and a pruritic skin rash on her shoulders for the last 6 months. She describes feeling bloated after meals. Over the past 3 months, she has had multiple loose bowel movements per day. She appears thin. She is at the 20th perc... | IgA tissue transglutaminase antibodies | {
"A": "Increased serum lipase",
"B": "Esophageal webs",
"C": "IgA tissue transglutaminase antibodies",
"D": "Oocysts on acid-fast stain\n\""
} | step2&3 | C | [
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"past 3 months",
"multiple loose bowel movements",
"day",
"appears thin",
"percentile",
"height",
"percentile",
"weight",
"temper... |
A 50-year old woman presents to her family physician 6 months after the death of her husband, who died following a car accident. She is crying inconsolably and reports that she no longer enjoys doing the things she and her husband once did together. She feels guilty for the time she wasted arguing with him in the past.... | ↓ Norepinephrine, ↓ Serotonin, ↓ Dopamine | {
"A": "↓ Norepinephrine, ↓ Serotonin, ↓ Dopamine",
"B": "Normal Norepinephrine, Normal Serotonin, ↓ Dopamine",
"C": "Normal Norepinephrine, Normal Serotonin, ↑ Dopamine",
"D": "Normal Norepinephrine, ↓ Serotonin, Normal Dopamine"
} | step1 | A | [
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"sleeping",
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"lacks",
"energy",
... |
A 56-year-old male with history of CHF presents to a trauma center following a motor vehicle accident. On arrival, his Glasgow Coma Scale score is 8, and he is found to have increased intracranial pressure. Mannitol is administered. Which of the following side effects of the drug would you most likely observe in this p... | Pulmonary edema | {
"A": "Seizures",
"B": "Pulmonary edema",
"C": "Arrhythmias",
"D": "Restrictive cardiomyopathy"
} | step1 | B | [
"year old male",
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"motor vehicle accident",
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"found to",
"increased intracranial pressure",
"Mannitol",
"administered",
"of",
"following side effects",
"drug",
"most likely observe",
"patient"
] |
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 ar... | High serum TSH | {
"A": "High serum TSH",
"B": "Psorasis",
"C": "Cheilosis",
"D": "Abdominal colic"
} | step2&3 | A | [
"year old white female presents",
"primary care physician",
"regular check-up",
"eating",
"healthy diet",
"balance",
"meat",
"vegetables",
"states",
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"wine",
"night",
"dinner",
"part of",
"evaluation",
"complete blood count",
"blood smear",
"performed",
"Hemoglobin",
"g... |
A 29-year-old woman presents to her primary physician with complaints of episodic late-night agitations and insomnia to an extent that her work is at stake due to her poor performance for months. Her husband reports that she has recently spent their savings on a shopping spree. He is worried that she might be taking il... | The patient should be informed about the risk of thyroid function impairment | {
"A": "The prescribed medication does not require therapeutic monitoring",
"B": "The patient should be informed about the risk of thyroid function impairment",
"C": "The medication can be discontinued abruptly when the patient’s symptoms ameliorate",
"D": "Patient can not be switched to any other therapy if th... | step1 | B | [
"29 year old woman presents",
"primary physician",
"complaints of episodic late night agitations",
"insomnia",
"extent",
"work",
"due to",
"poor performance",
"months",
"husband reports",
"recently spent",
"savings",
"shopping",
"worried",
"taking illicit substances",
"behavior changes... |
A 45-year-old primigravida woman at 13-weeks' gestation is scheduled for a prenatal evaluation. This is her first appointment, though she has known she is pregnant for several weeks. A quad screening is performed with the mother's blood and reveals the following:
AFP (alpha-fetoprotein) Decreased
hCG (human chorionic g... | Nondisjunction | {
"A": "Robertsonian translocation",
"B": "Nondisjunction",
"C": "Nucleotide excision repair defect",
"D": "Mosaicism"
} | step1 | B | [
"year old primigravida woman",
"weeks",
"gestation",
"scheduled",
"prenatal evaluation",
"first appointment",
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"pregnant",
"weeks",
"quad screening",
"performed",
"mother's blood",
"reveals",
"following",
"alpha-fetoprotein",
"Decreased hCG",
"human chorionic gonadotropin",
... |
A 39-year-old man comes to the physician because of a 3-month history of fatigue, decreased sexual desire, and difficulty achieving an erection. He has no past medical history except for a traumatic brain injury he sustained in a motor vehicle accident 4 months ago. At that time, neuroimaging studies showed no abnormal... | Dopamine | {
"A": "Dopamine",
"B": "Growth hormone",
"C": "Thyrotropin-releasing hormone",
"D": "Luteinizing hormone"
} | step1 | A | [
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"physician",
"3 month history",
"fatigue",
"decreased sexual desire",
"difficulty",
"erection",
"past medical history",
"traumatic brain injury",
"sustained",
"motor vehicle accident",
"months",
"time",
"neuroimaging studies showed",
"abnormalities",
"Physical examinati... |
A 27-year-old woman comes to her primary care physician complaining of palpitations. She reports that for the past 2 months she has felt anxious and states that her heart often feels like it’s “racing.” She also complains of sweating and unintentional weight loss. Physical examination reveals symmetrical, non-tender th... | Radioactive iodine | {
"A": "Methimazole",
"B": "Propranolol",
"C": "Propylthiouracil",
"D": "Radioactive iodine"
} | step2&3 | D | [
"27 year old woman",
"primary care physician",
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"reports",
"past",
"months",
"felt anxious",
"states",
"heart often feels",
"racing",
"sweating",
"unintentional weight loss",
"Physical examination reveals symmetrical",
"non-tender thyroid enlargement",
"exophthalmos",
"a... |
A 9-month-old infant presents to your office for a check-up. Exam reveals mental retardation, microcephaly, and a mousy odor to his breath. You should be concerned that the infant may have which of the following? | Deficit of phenylalanine hydroxylase activity | {
"A": "Deficit of phenylalanine hydroxylase activity",
"B": "Deficit of tyrosine hydroxylase activity",
"C": "Excess tetrahydrobiopterin cofactor",
"D": "Excess phenylalanine hydroxylase activity"
} | step1 | A | [
"month old infant presents",
"office",
"check-up",
"Exam reveals mental retardation",
"microcephaly",
"mousy odor",
"breath",
"concerned",
"infant",
"following"
] |
A previously healthy 16-year-old girl comes to the physician because of fever, fatigue, and a sore throat for 8 days. She also has a diffuse rash that started yesterday. Three days ago, she took amoxicillin that she had at home. She is sexually active with two male partners and uses condoms inconsistently. Her temperat... | Heterophile antibody test | {
"A": "Flow cytometry",
"B": "Anti-CMV IgM",
"C": "Throat swab culture",
"D": "Heterophile antibody test"
} | step1 | D | [
"healthy",
"year old girl",
"physician",
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"fatigue",
"sore throat",
"days",
"diffuse rash",
"started",
"Three days",
"took amoxicillin",
"at home",
"sexually active",
"two male partners",
"uses condoms",
"temperature",
"4C",
"pulse 99 min",
"blood",
"70 mm Hg",
"Exami... |
A 18-year-old college freshman scrapes his knee after falling from his bike. He applies some topical neomycin because he knows that it has antibiotic properties. As he is also in biology class, he decides to research the mechanism of action of neomycin and finds that it interferes with formation of the 30S initiation c... | Shine-Dalgarno sequence | {
"A": "Shine-Dalgarno sequence",
"B": "5' methyl-guanosine cap",
"C": "Kozak sequence",
"D": "UAA, UAG, and UGA codons"
} | step1 | A | [
"year old college",
"scrapes",
"knee",
"falling",
"bike",
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"antibiotic properties",
"biology class",
"to research",
"mechanism of action",
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"finds",
"interferes with formation",
"30S initiation complex",
"bacteria",
"messenger RNA",
"signal"... |
A 28-year-old man comes to the physician for the evaluation of a progressively worsening tremor in his hands and multiple falls over the past 3 months. The tremor occurs both at rest and with movement. He also reports decreased concentration and a loss of interest in his normal activities over this time period. He has ... | Penicillamine | {
"A": "Prednisolone",
"B": "Levodopa",
"C": "Deferoxamine",
"D": "Penicillamine"
} | step1 | D | [
"year old man",
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"hands",
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"rest",
"movement",
"reports decreased concentration",
"loss of interest",
"normal activities",
"time period",
"history of serious medical illness",
"takes",
"m... |
Following the death of an 18-year-old woman, the task force determines a fatal drug interaction as the cause. The medical error is attributed to the fatigue of the treating resident. The report includes information regarding the resident’s work hours: The resident received the patient at the 27th hour of his continuous... | The duty hour during which this resident received the patient | {
"A": "The duty hour during which this resident received the patient",
"B": "The maximum number of hours per week this resident was on duty",
"C": "The minimum rest hours this resident had between duty periods",
"D": "The maximum number of hours allowed for continued patient care"
} | step2&3 | A | [
"Following",
"death",
"year old woman",
"task force",
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"attributed",
"fatigue",
"treating resident",
"report includes information",
"residents work hours",
"resident received",
"patient",
"hour",
"continuous",
"preceding month",
"m... |
A 58-year-old woman with type 2 diabetes mellitus comes to the physician because of a 3-month history of right lower extremity pain and burning while walking. The pain subsides with rest. She has smoked one pack of cigarettes daily for the past 30 years. Her current medications include metformin, atorvastatin, and aspi... | Cilostazol | {
"A": "Dabigatran",
"B": "Eptifibatide",
"C": "Bosentan",
"D": "Cilostazol"
} | step1 | D | [
"58 year old woman",
"type 2 diabetes mellitus",
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"cigarettes daily",
"past 30 years",
"current medications include metformin",
"atorvastatin",
"aspirin",
"Examination shows",
"lack",
"... |
A 6-week-old girl is brought to the physician for a follow-up examination. She has had difficulty feeding with frequent regurgitation of milk and her mother is concerned that the child is not gaining weight appropriately. The mother reports that the girl's crying resembles a squeaky door. She is at the 2nd percentile f... | Microdeletion at chromosome 5 | {
"A": "Microdeletion at chromosome 5",
"B": "X-linked gene mutation",
"C": "Translocation at chromosome 21",
"D": "Maternal hypothyroidism"
} | step2&3 | A | [
"week old girl",
"brought",
"physician",
"follow-up examination",
"difficulty feeding",
"frequent regurgitation",
"milk",
"mother",
"concerned",
"child",
"not gaining weight",
"mother reports",
"girl's crying",
"door",
"2nd percentile",
"head circumference",
"percentile",
"height",... |
A 64-year-old man presents to the emergency department with acute onset of chest pain. He says the pain is substernal and radiates to his left arm. He has a history of hypertension, diabetes mellitus, erectile dysfunction, benign prostate hyperplasia, and panic disorder. He takes aspirin, lisinopril, metformin, sildena... | Medication interaction | {
"A": "Fibrinous pericarditis",
"B": "Medication interaction",
"C": "Myocardial wall rupture",
"D": "Stent thrombosis"
} | step2&3 | B | [
"64 year old man presents",
"emergency department",
"acute onset of chest pain",
"pain",
"radiates",
"left arm",
"history of hypertension",
"diabetes mellitus",
"erectile dysfunction",
"benign prostate hyperplasia",
"panic disorder",
"takes aspirin",
"lisinopril",
"metformin",
"sildenafi... |
A newborn male, delivered by emergency Cesarean section during the 28th week of gestation, has a birth weight of 1.2 kg (2.5 lb). He develops rapid breathing 4 hours after birth. Examination of the respiratory system reveals a respiratory rate of 80/min, expiratory grunting, intercostal and subcostal retractions with n... | Decreased blood flow in the vasa vasorum of the ductus arteriosus | {
"A": "Inhibition of lipoxygenase",
"B": "Increased synthesis of prostaglandin E2",
"C": "Decreased blood flow in the vasa vasorum of the ductus arteriosus",
"D": "Increased synthesis of platelet-derived growth factor (PDGF)"
} | step2&3 | C | [
"newborn male",
"delivered",
"emergency Cesarean section",
"week",
"gestation",
"birth weight",
"kg",
"2.5",
"rapid breathing",
"hours",
"birth",
"Examination of",
"respiratory system reveals",
"respiratory rate",
"80 min",
"expiratory grunting",
"subcostal retractions",
"nasal fla... |
A 60-year-old man presents to the clinic for his annual check-up. The patient says that he has occasional leg cramps, and his legs feel heavy especially after standing for long hours to teach his classes. His past medical history is significant for hypertension which is controlled by metoprolol and lisinopril. He has s... | Valvular incompetence of lower limb veins and increased venous pressure | {
"A": "Age-related fatigability",
"B": "Intramural thrombus in a deep vein of the leg",
"C": "Valvular incompetence of lower limb veins and increased venous pressure",
"D": "Atherosclerosis of medium- and large-sized arteries of the lower limb"
} | step1 | C | [
"60 year old man presents",
"clinic",
"annual check-up",
"patient",
"occasional leg cramps",
"legs feel heavy",
"standing",
"long hours to teach",
"classes",
"past medical history",
"significant",
"hypertension",
"controlled by metoprolol",
"lisinopril",
"smoked half",
"pack",
"cigar... |
A mother brings in her 7-year-old son because she is worried about his behavior after his teacher called. The patient’s mother says she was told that he has not been doing his assignments and frequently tells his teachers that he forgets about them. In addition, he tends to have a difficult time sitting still in class ... | Attention deficit hyperactivity disorder | {
"A": "Antisocial personality disorder",
"B": "Attention deficit hyperactivity disorder",
"C": "Oppositional defiant disorder",
"D": "Schizoid personality disorder"
} | step1 | B | [
"mother",
"year old son",
"worried",
"behavior",
"teacher called",
"patients mother",
"not",
"assignments",
"frequently",
"teachers",
"forgets",
"addition",
"to",
"difficult time sitting",
"class",
"frequently disrupts",
"children",
"behavior",
"about",
"months",
"recently",
... |
A 36-year-old primigravid woman at 8 weeks' gestation comes to the emergency department because of vaginal bleeding and mild suprapubic pain 1 hour ago. The bleeding has subsided and she has mild, brown spotting now. Her medications include folic acid and a multivitamin. She smoked one pack of cigarettes daily for 10 y... | Reassurance and follow-up ultrasonography | {
"A": "Reassurance and follow-up ultrasonography",
"B": "Low-dose aspirin therapy",
"C": "Progestin therapy",
"D": "Complete bed rest"
} | step2&3 | A | [
"36 year old primigravid woman",
"weeks",
"gestation",
"emergency department",
"vaginal bleeding",
"mild suprapubic",
"hour",
"bleeding",
"mild",
"brown spotting now",
"medications include folic acid",
"multivitamin",
"smoked one pack",
"cigarettes daily",
"10 years",
"drank alcohol oc... |
A 27-year-old man presents to his physician for a checkup. At presentation, he complains of anxiety and persistently mood. The patient’s comorbidities include chronic gastritis treated with Helicobacter pylori eradication therapy, and chronic pyelonephritis with stage 1 chronic kidney disease. His grandfather who was a... | 9-item patient health questionnaire | {
"A": "Esophagogastroduodenoscopy",
"B": "Mini mental state examination",
"C": "9-item patient health questionnaire",
"D": "Echocardiography"
} | step2&3 | C | [
"27 year old man presents",
"physician",
"checkup",
"presentation",
"anxiety",
"persistently mood",
"patients comorbidities include chronic gastritis treated with Helicobacter pylori eradication therapy",
"chronic pyelonephritis",
"stage 1",
"kidney disease",
"grandfather",
"heavy smoker",
"... |
A 25-year-old man is brought to the emergency department because of a 6-day history of fever and chills. During this period, he has had generalized weakness, chest pain, and night sweats. He has a bicuspid aortic valve and recurrent migraine attacks. He has smoked one pack of cigarettes daily for 5 years. He does not d... | Mechanical valve replacement of the aortic valve | {
"A": "Repeat echocardiography in 4 weeks",
"B": "Mechanical valve replacement of the aortic valve",
"C": "Porcine valve replacement of the aortic valve",
"D": "Cardiac MRI"
} | step2&3 | B | [
"year old man",
"brought",
"emergency department",
"6-day history",
"fever",
"chills",
"period",
"generalized weakness",
"chest pain",
"night sweats",
"bicuspid aortic valve",
"recurrent migraine attacks",
"smoked one pack",
"cigarettes daily",
"5 years",
"not drink alcohol",
"experi... |
A 34-year-old woman with Crohn disease comes to the physician because of a 4-week history of nausea, bloating, and epigastric pain that occurs after meals and radiates to the right shoulder. Four months ago, she underwent ileocecal resection for an acute intestinal obstruction. An ultrasound of the abdomen shows multip... | Decreased biliary concentration of bile acids | {
"A": "Increased hepatic cholesterol secretion",
"B": "Decreased fat absorption",
"C": "Decreased motility of the gallbladder",
"D": "Decreased biliary concentration of bile acids"
} | step1 | D | [
"year old woman",
"Crohn disease",
"physician",
"4 week history",
"nausea",
"bloating",
"epigastric pain",
"occurs",
"meals",
"radiates",
"right shoulder",
"Four months",
"ileocecal resection",
"acute intestinal obstruction",
"ultrasound of",
"abdomen shows multiple echogenic foci",
... |
Forty-five minutes after the spontaneous delivery of a male newborn at 39 weeks' gestation, a 27-year-old primigravid woman complains of worsening abdominal pain and dizziness. The patient was admitted to the hospital 5 hours prior because of spontaneous rupture of membranes. During labor, she experienced a brief episo... | Uterine inversion | {
"A": "Uterine rupture",
"B": "Retained placental products",
"C": "Uterine inversion",
"D": "Laceration of cervix\n\""
} | step2&3 | C | [
"Forty-five minutes",
"spontaneous delivery",
"male newborn",
"weeks",
"gestation",
"27 year old primigravid woman",
"worsening abdominal",
"dizziness",
"patient",
"admitted",
"hospital",
"hours prior",
"of spontaneous rupture",
"membranes",
"labor",
"experienced",
"brief episode of ... |
A 36-year-old woman is brought to the emergency department after the sudden onset of severe, generalized abdominal pain. The pain is constant and she describes it as 9 out of 10 in intensity. She has hypertension, hyperlipidemia, and chronic lower back pain. Menses occur at regular 28-day intervals with moderate flow a... | Perforation | {
"A": "Ruptured ectopic pregnancy",
"B": "Bowel obstruction",
"C": "Perforation",
"D": "Colorectal cancer"
} | step2&3 | C | [
"36 year old woman",
"brought",
"emergency department",
"sudden onset",
"severe",
"generalized abdominal pain",
"pain",
"constant",
"out",
"10",
"intensity",
"hypertension",
"hyperlipidemia",
"chronic lower back pain",
"Menses occur",
"regular",
"day intervals",
"moderate flow",
... |
An investigator is studying the role of different factors in inflammation and hemostasis. Alpha-granules from activated platelets are isolated and applied to a medium containing inactive platelets. When ristocetin is applied, the granules bind to GpIb receptors, inducing a conformational change in the platelets. Bindin... | Platelet adhesion | {
"A": "Platelet adhesion",
"B": "Platelet aggregation",
"C": "Local vasoconstriction",
"D": "Platelet activation"
} | step1 | A | [
"investigator",
"studying",
"role",
"different factors",
"inflammation",
"hemostasis",
"Alpha-granules",
"activated platelets",
"isolated",
"applied",
"medium containing inactive platelets",
"ristocetin",
"applied",
"granules bind",
"receptors",
"inducing",
"conformational change",
... |
A 14-year-old boy comes to the physician because of an itchy rash on his right arm for 1 day. The rash started as small papules, then progressed into blisters with oozing. He has had atopic dermatitis at the age of 6 years. His vital signs are within normal limits. A photograph of the patient's arm is shown. There is n... | Plants | {
"A": "Bees",
"B": "Plants",
"C": "Sun",
"D": "Gluten"
} | step2&3 | B | [
"year old boy",
"physician",
"of",
"itchy rash",
"right arm",
"1 day",
"rash started",
"small papules",
"then progressed",
"blisters",
"atopic dermatitis",
"age",
"6 years",
"vital signs",
"normal limits",
"photograph of",
"patient's arm",
"shown",
"lymphadenopathy",
"Avoidance... |
A 5-year-old girl presents with a rash and a persistent fever of 41.0°C (105.8°F), not relieved by Tylenol. The patient’s mother says that her symptoms started 5 days ago and have not improved. The rash started on her trunk and now is present everywhere including the palms and soles. Her birth history is normal. Her pu... | Kawasaki disease | {
"A": "Scarlet fever",
"B": "Juvenile rheumatoid arthritis",
"C": "Kawasaki disease",
"D": "Staphylococcal scalded skin syndrome"
} | step1 | C | [
"5 year old girl presents",
"rash",
"persistent fever",
"not relieved by Tylenol",
"patients mother",
"symptoms started 5 days",
"not improved",
"rash started",
"trunk",
"now",
"present",
"including",
"palms",
"soles",
"birth history",
"normal",
"pulse",
"min",
"respiratory rate"... |
A 24-year-old male graduate student presents to the physician for a 2-month history of persistent thoughts and anxiety that he is going to be harmed by someone on the street. The anxiety worsened after he witnessed a pedestrian being hit by a car 2 weeks ago. He states, “That was a warning sign.” On his way to school, ... | Delusional disorder | {
"A": "Avoidant personality disorder",
"B": "Delusional disorder",
"C": "Generalized anxiety disorder",
"D": "Schizophrenia"
} | step2&3 | B | [
"year old male graduate student presents",
"physician",
"2 month history",
"persistent thoughts",
"anxiety",
"to",
"street",
"anxiety worsened",
"witnessed",
"pedestrian",
"hit by",
"car 2 weeks",
"states",
"warning sign",
"school",
"now often leaves",
"hour earlier to take",
"hide... |
A 19-year-old woman presents to the emergency department with complaints of blurry vision and headaches that started 2 days ago. She reports that she has been experiencing some facial pain, but she thought it was related to her toothache. She is also worried about a black spot that is increasing in size on her face ove... | Mucormycosis | {
"A": "Bacillus anthracis",
"B": "Mucormycosis",
"C": "Aspergillus fumigatus",
"D": "Clostridium difficile"
} | step1 | B | [
"year old woman presents",
"emergency department",
"complaints",
"blurry vision",
"headaches",
"started 2 days",
"reports",
"experiencing",
"facial pain",
"thought",
"related",
"toothache",
"worried",
"black spot",
"increasing in size",
"face",
"month",
"concerns",
"frequency of ... |
A 35-year-old woman comes to the physician because of a 3-month history of headache, palpitations, diarrhea, and weight loss. She takes no medications. Her pulse is 110/min and blood pressure is 125/70 mm Hg. Examination shows warm, moist skin and diffuse hyperreflexia. An MRI of the brain shows a sellar mass. The unde... | G protein-coupled receptors | {
"A": "Intracytosolic nuclear receptor",
"B": "G protein-coupled receptors",
"C": "Membrane-bound guanylate cyclase",
"D": "Nonreceptor tyrosine kinase"
} | step1 | B | [
"35 year old woman",
"physician",
"of",
"3 month history",
"headache",
"palpitations",
"diarrhea",
"weight loss",
"takes",
"medications",
"pulse",
"min",
"blood pressure",
"70 mm Hg",
"Examination shows warm",
"moist",
"diffuse hyperreflexia",
"MRI of",
"brain shows",
"mass",
... |
A 27-year-old woman presents to her primary care physician for a wellness checkup. She states that she is currently doing well but is unable to engage in exercise secondary to her asthma. Her asthma is well-controlled at baseline, and her symptoms only arise when she is trying to exercise once a week at volleyball prac... | Recommend she use her albuterol inhaler prior to exercise | {
"A": "Add inhaled fluticasone to her asthma regimen",
"B": "Add montelukast to her asthma regimen",
"C": "Recommend cessation of athletic endeavors",
"D": "Recommend she use her albuterol inhaler prior to exercise"
} | step2&3 | D | [
"27 year old woman presents",
"primary care physician",
"wellness checkup",
"states",
"currently",
"well",
"unable",
"exercise secondary to",
"asthma",
"asthma",
"well-controlled",
"baseline",
"symptoms only",
"to exercise once",
"week",
"volleyball practice",
"currently only using",... |
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