Instructions: Given the medical questions below, return the medical difficulty/complexity of each question, please select among the following options:

1. Low: a PCP or general physician can answer this question without consulting a specialist.
2. Moderate: a PCP or general physician can answer this question in consultation with a specialist, and a single specialist can answer this question.
3. High: A team of multi-departmental specialists can answer this question, which requires specialists consulting to another department (Requires team effort to treat the case).

Question 1: A 47-year-old female undergoes a thyroidectomy for treatment of Graves' disease. Post-operatively, she reports a hoarse voice and difficulty speaking. You suspect that this is likely a complication of her recent surgery. What is the embryologic origin of the damaged nerve that is most likely causing this patient's hoarseness?

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Question 2: A clinical researcher is interested in creating a new drug for HIV patients. Darunavir has been particularly efficacious in recent patients; however, some have experienced an increased incidence of hyperglycemia. A new drug called DN501 is developed with the same mechanism of action as darunavir but fewer side effects. Which of the following is the mechanism of action of DN501?

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Question 3: A 14-year-old girl comes to the physician because she has not yet had her period. She is at the 10th percentile for height and 25th percentile for weight. Examination shows a broad chest with widely spaced nipples, a low posterior hairline, forearms angled 20° away from the body when fully extended, and shortened fourth metacarpals bilaterally. Sexual development is Tanner stage 1. Which of the following statements about this patient's fertility is most accurate?

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Question 4: A 15-year-old girl comes to the physician because she has not had menstrual bleeding for the past 3 months. Menses had previously occurred at irregular 15–45 day intervals with moderate to heavy flow. Menarche was at the age of 14 years. She started having sexual intercourse with her boyfriend about 3 months ago. Six months ago she had a manic episode, which was treated with risperidone. Her mother has PCOS and her father has diabetes mellitus. She is very conscious of her weight and appearance. She is 171 cm (5 ft 6 in) tall and weighs 79 kg (174 lb); BMI is 27.02 kg/m2. Her temperature is 37°C (98.6°F), pulse is 60/min, and blood pressure is 116/70 mm Hg. The abdomen is soft and nontender. Pelvic examination shows a normal vagina and cervix. Serum hormone studies show: Prolactin 16 ng/mL Thyroid-stimulating hormone 3.8 μU/mL Follicle-stimulating hormone 6 mIU/mL Luteinizing hormone 5.1 mIU/mL Progesterone 0.8 ng/mL (follicular N <3; luteal N >3–5) Testosterone 2.2 nmol/L (N <3.5) A urine pregnancy test is negative. Which of the following is the most likely cause of her symptoms?"

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Question 5: A 77-year-old man comes to your office for a routine visit. He is doing well, and his only complaint is the recent appearance of several brown greasy appearing lesions on his forehead (figure A) that he can't seem to peel off. What is the most likely diagnosis?

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Question 6: A 76-year-old woman visits a physician for a general medical examination. She is asymptomatic. Six months prior, she had a cerebral stroke with left hemiparesis, from which she has almost completely recovered with physiotherapy. She has a history of hypertension and atrial fibrillation (AF). She has no significant ischemic, valvular, or structural heart disease. She takes metoprolol, amlodipine, warfarin, and atorvastatin. Blood pressure is 125/70 mm Hg, pulse is 75/min with an irregular rhythm. Respirations are 13/min. She has a minor limp and weakness in her left arm and leg. Heart exam shows no abnormalities other than irregular beats. To assess adherence and therapeutic efficacy in this patient, which of the following studies should be ordered?

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Question 7: A 26-year-old G1P0 woman presents to her primary care physician’s office with feelings of anxiety and trouble with sleep. She finds it difficult initiating sleep, occasionally has palpitations, and feels fatigued. She denies having similar symptoms in the past or starting any new medications or illicit drugs. She is currently 10 weeks pregnant and is closely followed by her obstetrician. Her temperature is 98.6°F (37°C), blood pressure is 125/70 mmHg, pulse is 105/min, and respirations are 18/min. On physical exam, the patient is mildly diaphoretic. The skin is warm and the thyroid gland is diffusely enlarged with thyroid bruits. Laboratory studies are significant for a thyroid-stimulating hormone level of 0.01 µU/mL (normal is 0.5-5.0 µU/mL) and an elevated free thyroxine (FT4) that is inappropriate for her pregnancy. Which of the following is the best treatment option for this patient?

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Question 8: A 26-year-old female complains of frequent, large volume urination. This negatively affects her sleep, as she has to frequently wake up at night to urinate. She also complains of increased thirst. Her past medical history is significant for bipolar disorder that is treated with lithium for 3 years. Serum osmolality is 425 mOsm/kg, and urine osmolality is 176 mOsm/kg. Which of the following best explains this patient’s serum and urine osmolality?

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Question 9: A 14-year-old girl is brought to the physician by her father because of fever, chills, abdominal pain, and profuse non-bloody diarrhea. Her symptoms began one week ago, when she had several days of low-grade fever and constipation. She returned from Indonesia 2 weeks ago, where she spent the summer with her grandparents. Her temperature is 39.3°C (102.8°F). Examination shows diffuse abdominal tenderness and mild hepatosplenomegaly. There is a faint salmon-colored maculopapular rash on her trunk and abdomen. Which of the following is the most likely causal organism?

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Question 10: A 30-year-old African American woman comes to the physician for the evaluation of a dry cough and chest discomfort for the past 3 days. During this period, the patient has had headaches, muscle aches, joint pain, fever, and chills. Ten days ago, she was hiking with her family in Mississippi. The patient has asthma that is treated with an albuterol inhaler. Her mother has a lung disease treated with methotrexate. The patient has smoked one pack of cigarettes daily for the past 10 years. Her temperature is 38°C (100.4°F). Physical examination shows slight wheezes throughout both lung fields. Laboratory studies and urinalysis are positive for polysaccharide antigen. Bronchoalveolar lavage using silver/PAS-staining shows macrophages filled with a dimorphic fungus with septate hyphae. Which of the following is the most likely cause of this patient's symptoms?

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Question 11: A 70-year-old woman with no significant medical history begins to experience memory loss and personality changes. Over the next few months, her symptoms become more severe, as she experiences rapid mental deterioration. She also starts to have sudden, jerking movements in response to being startled and gait disturbances. Eventually, she lapses into a coma and dies eight months after the onset of symptoms. What process likely caused this woman's illness?

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Question 12: A 27-year-old woman, gravida 2, para 1, at 40 weeks' gestation is admitted to the hospital in active labor. The patient reports severe pelvic pain. Pregnancy has been complicated by gestational diabetes. Pregnancy and delivery of her first child were uncomplicated. Current medications include insulin, folic acid, and a multivitamin. Vital signs are within normal limits. The cervix is 100% effaced and 10 cm dilated; the vertex is at -1 station. The fetal heart rate is reactive with no decelerations. Epidural anesthesia is performed and the patient's symptoms improve. Ten minutes later, the patient has dizziness. Her pulse is 68/min, respirations are 16/min, and blood pressure is 90/60 mm Hg. Intravenous fluid resuscitation is begun. Which of the following is the most likely underlying cause of the patient's hypotension?

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Question 13: A 75-year-old woman is brought by a patrolman to the emergency department because of altered mental status. She was found wandering next to the highway. The patient was unable to answer questions and collapsed in transit. Her vitals are: temperature, 33.0°C (91.4°F); pulse, 40/min; respirations,12/min; blood pressure, 80/50 mm Hg; and oxygen saturation, 85% on room air. Physical examination shows decorticate posturing, incomprehensible speech, eyes opening to pain, dry hair, coarse and waxy skin, and non-pitting edema around the face and all extremities. Electrocardiogram shows sinus bradycardia. Laboratory studies show: Calcium 9.0 mg/dL Hematocrit (female) 34% Potassium 4.0 mEq/L Sodium 120 mEq/L TSH 110.0 µU/mL Thyroxine (T4) 1.2 µg/dL Triiodothyronine (T3) 70 ng/dL Which of the following is the most likely diagnosis in this patient?

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Question 14: A 35-year-old man visits your office for his annual health checkup. He was diagnosed with generalized anxiety disorder 6 months ago, which is being treated with citalopram. He comments that his symptoms have improved since initiating the prescribed therapy; however, in the past 2 months, he has been unable to have sexual intercourse due to weak tumescence and low libido. His blood pressure is 122/74 mm Hg, heart rate is 75/min, and respiratory rate is 16/min. Physical examination reveals regular heart and lung sounds. What is the appropriate step in the management of this patient?

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Question 15: A 51-year-old man presents to his primary care provider complaining of malaise. He returned from a research trip to Madagascar 2 weeks ago and has since developed a worsening fever with a maximum temperature of 102.2°F (39°C). He also reports some swelling around his neck and groin. He works as a zoologist and was in rural Madagascar studying a rare species of lemur. His past medical history is notable for hypertension and gout. He takes lisinopril and allopurinol. His temperature is 101.9°F (38.3°C), blood pressure is 145/85 mmHg, pulse is 110/min, and respirations are 22/min. On exam, he has painful erythematous cervical, axillary, and inguinal lymphadenopathy. Black hemorrhagic eschars are noted on his fingertips bilaterally. The pathogen responsible for this patient’s condition produces a virulence factor that has which of the following functions?

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Question 16: A 40-year-old man presents to the clinic with complaints of increased bilateral pain in his knees. The pain developed over time and now limits his mobility. He states that the pain is worse at the end of the day, though he does have some early-morning stiffness lasting about 20 minutes. He used to have some success with over-the-counter NSAIDs; however, they no longer help. The patient also has been taking metformin for the past 2 years and is severely obese, with a BMI of 41 kg/m2. Additionally, he states that he has felt increasingly tired during the day, often dozes off during work, and no longer feels refreshed when he wakes up in the morning. Upon examination, there is no tenderness on palpation or erythema; however, some crepitus is felt. He has no other complaints but has a family history of rheumatoid arthritis (RA) on his mother’s side. Which of the following factors is the underlying cause of the patient’s pain, as well as the rest of his complaints?

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Question 17: A 49-year-old woman comes to the physician for a scheduled colposcopy. Two weeks ago, she had a routine Pap smear that showed atypical squamous cells. Colposcopy shows an area of white discoloration of the cervix with application of acetic acid solution. Biopsy of this area shows carcinoma-in-situ. Activation of which of the following best explains the pathogenesis of this condition?

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Question 18: A 40-year-old patient is brought into the emergency department after suffering a motor vehicle crash where he was pinned underneath his motorcycle for about 30 minutes before a passerby called 911. While evaluating him per your institution's trauma guidelines, you discover pain upon palpation of his right lower extremity which is much larger than his left counterpart. The patient admits to decreased sensation over his right lower extremity and cannot move his leg. There are no palpable dorsalis pedis or posterior tibial pulses on this extremity, and it is colder and paler in comparison to his left side. Measured compartment pressure of his distal right leg is 35 mm Hg. What is the next best step in this patient's care?

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Question 19: A 39-year-old man presents to his primary care physician because he has been having severe headaches and fever for the last 2 days. He also says his right eyelid has been painlessly swelling and is starting to block his vision from that eye. He recently returned from a tour of the world where he visited Thailand, Ethiopia, and Brazil. Otherwise his past medical history is unremarkable. On presentation, his temperature is 102°F (38.8°C), blood pressure is 126/81 mmHg, pulse is 125/min, and respirations are 13/min. Physical exam reveals a nontender swelling of the right eyelid, lymphadenopathy, and an indurated red patch with surrounding erythema and local swelling on his left leg. Which of the following drugs should be used to treat this patient's condition?

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Question 20: An 80-year-old man is brought to the emergency department because of fatigue and lightheadedness. He does not have chest pain, palpitations, or difficulty breathing. He has a history of hyperlipidemia, type 2 diabetes mellitus, hypertension, osteoarthritis, and asthma. Current medications include simvastatin, metformin, lisinopril, albuterol, and ibuprofen. His pulse is 48/min and blood pressure is 89/50 mm Hg. He responds slowly to questions but is oriented to person, place, and time. Examination shows dry mucous membranes. His lungs are clear to auscultation and bowel sounds are positive with no pulsatile masses or bruits. Pedal pulses are nonpalpable, distal extremities are cold, and capillary refill time is 4 seconds. An ECG shows left axis deviation, a Q wave in lead III, a constant PR interval of 0.15 seconds with every third P wave that is nonconducted, and a QRS interval of .09 seconds. Which of the following is the most appropriate next step in management?

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Question 21: A 45-year-old man presents to the emergency department with weakness. He states that it started yesterday and has been progressively worsening. Initially, he noticed blurry vision and some trouble speaking and swallowing but thought he was just coming down with a cold. He then noticed weakness of his facial muscles and shortness of breath. The patient works as a farmer and harvests and cans his own foods. He has had diarrhea recently and a cough prior to these symptoms of weakness. His temperature is 97.9°F (36.6°C), blood pressure is 144/94 mmHg, pulse is 87/min, respirations are 18/min, and oxygen saturation is 94% on room air. Physical exam is notable for a man who seems unable to smile with dysarthric speech. He takes shallow and weak breaths on pulmonary exam. The patient demonstrates 3/5 strength with diminished reflexes in his upper extremities. The patient is subsequently intubated. Which of the following is the best treatment for this patient?

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Question 22: A 64-year-old man with multiple sclerosis comes to the physician because of a 4-month history of urinary incontinence. The urge to urinate occurs suddenly, and he often is unable to make it to the bathroom before leaking urine. He has no incontinence with coughing or laughing. Digital rectal examination shows no abnormalities. Ultrasonography shows a normal post-void residual volume. Which of the following is the most appropriate pharmacotherapy for this patient's incontinence?

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Question 23: A 75-year-old man presents to his physician with a 1-year history of dysphagia for solids. His more recent complaints include dysphagia for liquids as well. The patient states that he has no difficulty initiating swallowing but occasionally food is stuck in his throat. He does not complain of pain while swallowing but has noticed minor unintentional weight loss. The patient has no history of speech-related pain or nasal regurgitation. His family history is unremarkable. During the examination, the patient appears ill, malnourished, and slightly pale. He is not jaundiced nor cyanotic. Physical examination is unremarkable. A swallowing study reveals a small outpouching in the posterior neck (see image). Which nerve is most likely involved in this patient’s symptoms?

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Question 24: A 45-year-old mechanic presents to the emergency department complaining of acute-onset shortness of breath while repairing a plowing tractor for his neighbor. The patient denies having any history of asthma or respiratory symptoms, and does not smoke. His temperature is 99.8°F (37.7°C), pulse is 65/min, blood pressure is 126/86 mmHg, and respirations are 20/min. His oxygen saturation is 97%. On exam, he is pale and diaphoretic. His pupils are contracted. Diffuse wheezes are noted in all lung fields. What is the best treatment for his condition?

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Question 25: A 23-year-old primigravida presents for a regular prenatal care visit at 16 weeks gestation. She complains of increased fatigability, but is otherwise well. She takes folic acid, iron, and vitamin D supplementation. Her vital signs are as follows: blood pressure, 110/70 mm Hg; heart rate, 86/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉). The physical examination is unremarkable. The complete blood count results are as below: Erythrocyte count 3.9 million/mm3 Hb 11.1 g/dL HCT 32% Reticulocyte count 0.2% MCV 90 fL Platelet count 210,000/mm3 Leukocyte count 8,100/mm3 Which of the following tests is required to investigate the cause of the patient’s laboratory findings?

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Question 26: A 32-year-old male presents to the emergency department because of fever and diarrhea. He was in his normal state of health until 2 weeks ago when he went abroad on a vacation. During his trip he went kayaking, visited spas, interacted with local animals, and ate local foods. Since returning he has had 3-day history of fever, cough, headache, and diarrhea. He drinks socially and has a 15-pack-year history of smoking. On presentation his temperature is 102.3°F (39.1°C), blood pressure is 105/62 mmHg, pulse is 91/min, respirations are 18/min, and O2 saturation is 91% on room air. Chest exam reveals fine crackles on auscultation. Chest radiograph reveals patchy infiltrates in both lungs and labs reveal mild hyponatremia and mild elevation of AST/ALT levels. The organism that is most likely responsible for this patient's symptoms is associated with which of the following characteristics?

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Question 27: A 42-year-old man comes to the physician after elevated liver function tests were found after a routine screening. He has had occasional headaches over the past year, but otherwise feels well. The patient reports that he was involved in a severe car accident 30 years ago. He does not smoke or drink alcohol. He has never used illicit intravenous drugs. He takes no medications and has no known allergies. His father had a history of alcoholism and died of liver cancer. The patient appears thin. His temperature is 37.8°C (100°F), pulse is 100/min, and blood pressure is 110/70 mm Hg. Physical examination shows no abnormalities. Laboratory studies show: Hemoglobin 14 g/dL Leukocyte count 10,000/mm3 Platelet count 146,000/mm3 Serum Glucose 150 mg/dL Albumin 3.2 g/dL Total bilirubin 1.5 mg/dL Alkaline phosphatase 75 U/L AST 95 U/L ALT 73 U/L HIV negative Hepatitis B surface antigen negative Hepatitis C antibody positive HCV RNA positive HCV genotype 1 A liver biopsy is performed and shows mononuclear infiltrates that are limited to portal tracts and periportal hepatocyte necrosis. Which of the following is the most appropriate next step in management?"

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Question 28: An 8-year-old boy is brought to the physician by his parents for short stature. Neither his clothing nor his shoe size have changed over the past year. He also frequently bumps into obstacles such as furniture and has headaches at night. He is always thirsty for cold water and has been urinating more frequently. Three years ago, he had an asthma attack that was treated with albuterol and a one-week course of steroids. His mother has Hashimoto's thyroiditis and had precocious puberty. His mother's height is 147 cm (4 ft 10 in) and his father's height is 160 cm (5 ft 3 in). He is at the 5th percentile for height and 5th percentile for weight. His temperature is 37°C (98.6°F), pulse is 98/min, respirations are 16/min, and blood pressure is 100/64 mm Hg. Examination shows a soft and nontender abdomen. The genitals and pubic hair are both Tanner stage 1. Axillary hair is absent. Patellar reflexes are 1+ bilaterally. Laboratory studies show: Na+ 145 mEq/L K+ 4.1 mEq/L Cl- 102 mEq/L HCO3- 25 mEq/L Ca2+ 9.4 mg/dL Glucose 110 mg/dL Thyroid-stimulating hormone 0.3 μU/mL Thyroxine 3.9 μg/dL Insulin-like growth factor 1 24 ng/mL (N=61–356 ng/mL) Insulin-like growth factor binding protein 3 2.1 mcg/mL (N=1.6–6.5 μg/mL) Which of the following is the most likely diagnosis?"

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Question 29: A 24-year-old man is brought in to the emergency department by his parents who found him in his room barely responsive and with slurring speech. The patients’ parents say that a bottle of oxycodone was found at his bedside and was missing 15 pills. On physical examination, the patient appears drowsy and lethargic and is minimally responsive to stimuli. His respiratory rate is 8/min and shallow, blood pressure is 130/90 mm Hg, and pulse is 60/min. On physical examination, miosis is present, and the pupils appear pinpoint. The patient is given a drug to improve his symptoms. Which of the following is the mechanism of action of the drug that was most likely administered?

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Question 30: A 52-year-old woman presents with a complaint of headache for the past 10 days. Her headache is diffuse, dull in character, moderate in intensity, and is worse in the morning. It is not associated with fever and sensitivity to light or sound. She experiences occasional nausea but no vomiting. She did not have similar headaches in the past. Her blood pressure is 140/90 mm Hg; pulse, 60/min, and body mass index is 33.5 kg/m2. The neurological examination reveals normal extraocular movements. Mild bilateral papilledema is present. A magnetic resonance imaging of the brain reveals a solitary lesion in the left temporal region with predominant hemorrhage. Refer to the image below of the MRI of the brain. Which of the following types of cancer has the highest tendency to cause this brain lesion?

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Question 31: A 29-year-old woman presents to her primary care doctor with a lesion on her left labia. She first noticed the lesion 3 days ago. The patient describes the lesion as painful and swollen. She denies vaginal discharge. Her past medical history is notable for mild intermittent asthma, gout, and obesity. She uses an albuterol inhaler as needed and takes allopurinol. She has had 5 sexual partners in the past year and uses the pull-out method for contraception. She has a 10-pack-year smoking history and drinks 10-12 alcoholic beverages per week. On exam, she has an ulcerated, tender, and purulent ulcer on the left labia majora. The patient has mild unilateral painful inguinal lymphadenopathy. This patient's condition is most likely caused by which of the following pathogens?

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Question 32: The parents of a 14-year-old patient are concerned and have questions about the use of insulin for their son’s recently diagnosed type 1 diabetes. The patient has developed an upper respiratory infection while at school. He is coughing and has a runny nose. His temperature is 37.8° C (100.2° F) and vital signs are within normal limits. Physical examination is unremarkable. Which of the following modifications to his insulin regimen would you recommend to this patient and his parents?

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Question 33: A 35-year-old woman comes to the physician for genetic counseling prior to conception. Her younger brother has mild developmental delay, pale complexion, and has to limit his dietary intake of phenylalanine. She has no similar symptoms and is in good health. Her parents are healthy. Which of the following is the most appropriate assessment of her carrier status for the disease affecting her brother?

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Question 34: A 73-year-old woman is brought to the physician by her daughter for evaluation of impaired memory and word-finding difficulties for 2 years. She was recently asked to step down from her position as volunteer accountant for a local charity organization because she was no longer able to coordinate her tasks. She reports that she has become unable to taste or smell her food. Two years later, the patient dies. At autopsy, examination of the brain shows generalized cortical atrophy. A photomicrograph of a section of the brain is shown. The inclusions indicated by the arrows are predominantly composed of which of the following substances?

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Question 35: Two weeks after undergoing an emergency cardiac catherization with stenting for unstable angina pectoris, a 61-year-old man has decreased urinary output and malaise. He has type 2 diabetes mellitus and osteoarthritis of the hips. Prior to admission, his medications were insulin and naproxen. He was also started on aspirin, clopidogrel, and metoprolol after the coronary intervention. His temperature is 38°C (100.4°F), pulse is 93/min, and blood pressure is 125/85 mm Hg. Examination shows mottled, reticulated purplish discoloration of the feet. Laboratory studies show: Hemoglobin count 14 g/dL Leukocyte count 16,400/mm3 Segmented neutrophils 56% Eosinophils 11% Lymphocytes 31% Monocytes 2% Platelet count 260,000/mm3 Erythrocyte sedimentation rate 68 mm/h Serum Urea nitrogen 25 mg/dL Creatinine 4.2 mg/dL Renal biopsy shows intravascular spindle-shaped vacuoles. Which of the following is the most likely cause of this patient's symptoms?"

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Question 36: A 62-year-old Caucasian male presents to the emergency room with severe substernal chest pain, diaphoresis, and nausea. Imaging reveals transmural myocardial infarction in the posterior 1/3 of the ventricular septum. Which of this patient's coronary arteries is most likely occluded?

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Question 37: A 36-year-old nursing home worker presents to the clinic with the complaints of breathlessness, cough, and night sweats for the past 2 months. She further expresses her concerns about the possibility of contracting tuberculosis as one of the patients under her care is being treated for tuberculosis. A PPD skin test is done and reads 11 mm on day 3. Chest X-ray demonstrates a cavitary lesion in the right upper lobe. The standard anti-tuberculosis medication regimen is started. At a follow-up appointment 3 months later the patient presents with fatigue. She has also been experiencing occasional dizziness, weakness, and numbness in her feet. Physical exam is positive for conjunctival pallor. Lab work is significant for a hemoglobin level of 10 g/dL and mean corpuscular volume of 68 fl. What is the most likely cause of her current symptoms?

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Question 38: The first 24 hours after delivery, a 2888 g (6.37 lb) male newborn is not feeding well, has a high-pitched cry, and is diaphoretic. He was born at 38 weeks' gestation to a 30-year-old woman, gravida 2, para 1, after an uncomplicated labor and delivery. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The mother did not receive prenatal care. She takes codeine syrup frequently for dry cough. The infant's temperature is 37.8°C (100°F), pulse is 165/min, and blood pressure is 83/50 mm Hg. Examination shows hyperreflexia, tremors, and an excessive startle response. The baby is swaddled to prevent excoriations, and fluid resuscitation is initiated. Complete blood count and serum levels of glucose, bilirubin, and calcium are within normal limits. What is the most appropriate next step in treatment of this newborn?

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Question 39: A 66-year-old male with a history of myocardial infarction presents to your primary care office with complaints of dyspnea on exertion and swollen feet and ankles. On exam, you note an elevated JVP and 2+ pitting edema of bilateral lower extremities. What is the most likely explanation for this patient's lower extremity edema?

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Question 40: A 25-year-old female presents to urgent care with complaints of one day of burning and pain with urination, urgency, and frequency. She denies having a fever but has experienced intermittent chills. She is sexually active and inconsistently uses condoms. The patient has no past medical history. She is allergic to sulfa drugs. Physical examination of the genitalia is normal. Urinalysis shows positive leukocyte esterase and nitrites. The urine culture demonstrates gram-negative rods that form pink colonies on MacConkey agar. She is treated with an antibiotic and her symptoms quickly improve. The mechanism of the antibiotic she was most likely treated with is which of the following?

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Question 41: A 13-year-old boy is brought to the emergency department because of pain in his right knee for the past week. The pain is exacerbated by jogging and climbing up stairs. He has no history of trauma to the knee. He is otherwise healthy. He is an active member of his school's gymnastics team. His vital signs are within normal limits. Examination of the right knee shows a tender swelling at the proximal tibia; range of motion is full. Knee extension against resistance causes pain in the anterior proximal tibia. The remainder of the examinations shows no abnormalities. X-ray of the right knee shows anterior tibial soft tissue swelling with fragmentation of the tibial tuberosity. Which of the following is the most appropriate next step?

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Question 42: A 26-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision in which she was a restrained passenger. On arrival, she is lethargic and incoherent. She has severe facial lacerations and is in respiratory distress. Her pulse is 130/min, respirations are 29/min, and blood pressure is 90/58 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 70%. Examination shows multiple facial lacerations. There is dullness to percussion and decreased breath sounds over the left lung base. Abdominal examination shows diffuse tenderness with no guarding or rebound. Bowel sounds are normal. The remainder of the examination shows no abnormalities. Her hemoglobin concentration is 12.1 g/dL. An x-ray of the chest shows a fractured left second rib, depression of the left mainstem bronchus, deviation of the nasogastric tube to the right, and a widened mediastinum. Which of the following is the most likely diagnosis?

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Question 43: A 44-year-old man comes to the clinic because of a 6-month history of progressive fatigue. He has a history of intravenous heroin use. Physical examination shows scleral icterus. A serum study is positive for hepatitis C RNA. Therapy with interferon-α is initiated in combination with a second drug. The expected beneficial effect of the additional drug is most likely due to inhibition of which of the following enzymes?

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Question 44: A 22-year-old primigravida presents for a regular prenatal visit at 16 weeks gestation. She is concerned about the results of a dipstick test she performed at home, which showed 1+ glucose. She does not know if her liquid consumption has increased, but she urinates more frequently than before. The course of her pregnancy has been unremarkable and she has no significant co-morbidities. The BMI is 25.6 kg/cm2 and she has gained 3 kg (6.72 lb) during the pregnancy. The blood pressure is 110/80 mm Hg, the heart rate is 82/min, the respiratory rate is 14/min, and the temperature is 36.6℃ (97.9℉). The lungs are clear to auscultation, the heart sounds are normal with no murmurs, and there is no abdominal or costovertebral angle tenderness. The laboratory tests show the following results: Fasting glucose 97 mg/L ALT 12 IU/L AST 14 IU/L Total bilirubin 0.8 mg/dL(15 µmol/L) Plasma creatinine 0.7 mg/dL (61.9 µmol/L) Which of the following tests are indicated to determine the cause of the abnormal dipstick test results?

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Question 45: A 16-year-old boy is brought to the emergency department by ambulance from a soccer game. During the game, he was about to kick the ball when another player collided with his leg from the front. He was unable to stand up after this collision and reported severe knee pain. On presentation, he was found to have a mild knee effusion. Physical exam showed that his knee could be pushed posteriorly at 90 degrees of flexion but it could not be pulled anteriorly in the same position. The anatomic structure that was most likely injured in this patient has which of the following characteristics?

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Question 46: A 67-year-old man with chronic kidney disease comes to the physician because of worsening fatigue and shortness of breath on exertion for 6 months. He has a 20-year history of poorly-controlled type 2 diabetes mellitus. Current medications include metformin and insulin. His pulse is 105/min. Examination shows conjunctival pallor and bounding pulses. Laboratory studies show: Hemoglobin 8.6 g/dL Mean corpuscular volume 90 μm3 Reticulocyte count 0.5% Serum Ferritin 325 ng/mL Urea nitrogen 45 mg/dL Creatinine 2.2 mg/dL The patient is prescribed a drug to treat the cause of his current symptoms. The drug's mechanism of action directly involves which of the following signaling pathways?"

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Question 47: A 26-year-old nurse comes to the physician because of a 2-month history of fatigue. She has had a lot of stress at work and has been on sick leave for 2 weeks, but states that she would like to return to work. She has had several episodes of lower abdominal pain. She says, ""I know I have cancer."" She requests a diagnostic laparoscopy. She was diagnosed with peptic ulcer disease 6 months ago. Her only medication is omeprazole. The patient appears pale. Her temperature is 36.5° C (97.7° F), pulse is 120/min, and blood pressure is 90/65 mm Hg. On mental status examination she is tired and has a depressed mood. Physical examination shows pale conjunctivae and dry mucous membranes. There are numerous crusts along the course of her left arm veins. A grade 2/6 systolic ejection murmur is heard along the right-upper sternal border. Abdominal examination shows no abnormalities. There is generalized weakness of the proximal muscles. Laboratory studies show: Hemoglobin 7.5 g/dL Mean corpuscular volume 89 μm3 Reticulocyte count 13.3% Serum Sodium 139 mEq/L Potassium 3.9 mEq/L Calcium 8.5 mg/dL Test of the stool for occult blood is negative. Abdominal ultrasonography show no abnormalities. Which of the following is the most likely diagnosis?"

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Question 48: A 36-year-old woman, gravida 2, para 2, comes to the emergency department because of sudden-onset, severe right flank pain. She was in her aerobics class when the pain started but denies any trauma to the region. She has a history of recurrent ovarian cysts. Menses occur regularly at 28-day intervals. Her temperature is 37.1°C (99.3°F). Abdominal examination shows tenderness in the right lower quadrant with guarding. Pelvic ultrasound shows a large simple cyst on the right ovary. Right ovarian artery flow is detectable on Doppler, but there is no flow detected in the right ovarian vein. Which of the following ligaments is most likely to have been involved?

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Question 49: A 3-year-old refugee with increasing pitting edema and abdominal swelling over the past 2 months is brought to the physician. Her family has been displaced several times over the last few years. Nutrition and housing were frequently inadequate. At the physician’s clinic, the boy appears irritated and drowsy. He is difficult to arouse. Physical examination shows pitting edema over the ankles and feet and around his eyes. Abdominal examination is positive for ascites and hepatomegaly. Oral examination shows several missing teeth. Which of the following best explains these findings?

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Question 50: A 24-year-old married woman presents to the emergency department with severe abdominal pain since last night. She also complains of scant vaginal bleeding. She says she visited a physician last year who said she had a pelvic infection, but she was never treated because of insurance issues. She also says her period has been delayed this month. She is afebrile. The pulse is 124/min and the blood pressure is 100/70 mm Hg. On examination, her abdomen is distended and tender. A pregnancy test was positive. A complication of infection with which of the following organisms most likely led to this patient’s condition?

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