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91 | Over 1 year, a study is conducted to assess the antileukemic activity of a new tyrosine kinase inhibitor in patients with chronic myeloid leukemia in blast crisis. All patients enrolled in the study are informed that they would be treated with the tyrosine kinase inhibitor. They are assigned to successive dose cohorts ... | Case-control study | Crossover study | Open-labeled clinical trial | Randomized clinical trial | Single-blind, randomized, controlled trial | null | null | null | null | null | C | Open-labeled clinical trial | Text | STEP 1 | 0.86 | 111.21 | hard | 0 | C | C | C | easy |
288 | A previously healthy 52-year-old woman comes to the physician because of a 2-month history of fatigue, constipation, and frequent urination. Her temperature is 37.1°C (98.8°F), pulse is 80/min, respirations are 14/min, and blood pressure is 140/90 mm Hg. Diffuse crackles are heard bilaterally. Her serum calcium concent... | Calcitriol production by activated macrophages | Local resorption of bone by metastases | Parathyroid hormone-related peptide secretion | Secretion of parathyroid hormone | Secretion of thyroid-stimulating hormone | null | null | null | null | null | A | Calcitriol production by activated macrophages | Text | STEP 1 | 0.44 | 83.94 | medium | 1 | A | C | C | hard |
160 | A 42-year-old woman is brought to the emergency department 10 minutes after being involved in a high-speed motor vehicle collision in which she was a restrained passenger. On arrival, she has shortness of breath and abdominal pain. Her pulse is 135/min, respirations are 30/min, and blood pressure is 80/40 mm Hg. Breat... | CT scan of the abdomen | CT scan of the chest | Thoracoscopy | Laparotomy | Thoracotomy | null | null | null | null | null | D | Laparotomy | Text | STEP 2 | 0.64 | 87.82 | hard | 2 | D | B | D | medium |
514 | A 37-year-old woman comes to the office for a routine health maintenance examination. For the past 6 years, she has worked in a paper mill factory that uses liquid chlorine to bleach the paper. The patient is concerned about her exposure to toxic substances. Vital signs are within normal limits. Examination shows no ab... | Corticosteroid therapy | Taking frequent breaks from the paper-bleaching area | Undergoing monthly pulmonary function testing | Using a respirator at work | Washing daily after work with a chlorhexidine-based solution | null | null | null | null | null | D | Using a respirator at work | Text | STEP 2 | 0.5 | 54.87 | medium | 3 | D | D | D | easy |
452 | A 71-year-old woman comes to the physician because of a 5-day history of a painful rash. The rash began as a burning sensation over the right lower side of her chest. Three days ago, small, flat, painful macules appeared that rapidly progressed to vesicular lesions. During this period, the pain has continually increase... | Cellular | Complement | Humoral | Phagocytic cell | Toll-like receptor | null | null | null | null | null | A | Cellular | PIX | STEP 1 | 0.4 | 69.11 | medium | 4 | A | B | B | hard |
479 | A 1-month-old boy is brought to the emergency department because of a 1-day history of fever and cough. His temperature is 38.2°C (100.8°F), pulse is 140/min, and respirations are 54/min. Physical examination shows intercostal retractions. Wheezes are heard in all lung fields. A blood culture grows coagulase-negative, ... | Staphylococcus aureus, contaminant | Staphylococcus aureus, pathogen | Staphylococcus epidermidis, contaminant | Staphylococcus epidermidis, pathogen | Streptococcus pneumoniae, contaminant | Streptococcus pneumoniae, pathogen | Streptococcus sanguis, contaminant | Streptococcus sanguis, pathogen | null | null | C | Staphylococcus epidermidis, contaminant | Text | STEP 1 | 0.28 | 86.08 | easy | 5 | C | D | C | medium |
228 | A 32-year-old woman comes to the physician because of fatigue for 6 months. She has had progressively severe dyspnea on exertion for 6 weeks. She had an extensive abdominal operation 5 years ago for Crohn disease. She does not take any medications. Her temperature is 37°C (98.6°F), pulse is 62/min, respirations are... | Acute leukemia | Anemia of chronic disease | Folic acid deficiency | Iron deficiency | Lyme disease | Microangiopathic hemolytic anemia | Pernicious anemia | Sleep apnea | null | null | D | Iron deficiency | Text | STEP 2 | 0.72 | 100.58 | hard | 6 | D | F | D | medium |
635 | A 45-year-old man is brought to the emergency department because of moderate chest pain after a generalized tonic-clonic seizure 30 minutes ago. He has seizure disorder for which he has taken carbamazepine and phenobarbital for the past 20 years. X-ray of the chest shows generalized osteopenia with several rib fracture... | Folic acid | Iron | Magnesium | Vitamin B2 (riboflavin) | Vitamin D | Zinc | null | null | null | null | E | Vitamin D | Text | STEP 2 | 0.44 | 68.63 | medium | 7 | E | E | E | easy |
624 | Researchers from a large neurology center are conducting a study to examine the relationship between stress levels and fibromyalgia-related pain. Two hundred patients with fibromyalgia are randomly selected from the center for participation in the study. During recruitment, a baseline interview is conducted with each p... | Matching | Post hoc analysis | Randomization | Standardization | Stratification | null | null | null | null | null | E | Stratification | Text | STEP 3 | 1.12 | 88.47 | hard | 8 | E | S | E | medium |
576 | A 9-month-old boy is brought to the office by his mother for a well-child examination. He was born at 32 weeks’ gestation because of spontaneous rupture of membranes. Growth and development are appropriate for age. His mother says he can sit without support and is interactive. She is concerned that he still takes two t... | Gastroesophageal reflux | Hypoglycemia | Obstructive sleep apnea | Parasomnia | Normal development | null | null | null | null | null | E | Normal development | Text | STEP 1 | 0.1 | 64.1 | easy | 9 | E | E | E | easy |
281 | A 46-year-old woman comes to the office because of a 4-month history of irregular vaginal bleeding that occurs every 2 weeks and lasts 3 to 5 days. Until 5 months ago when she missed a period, her periods had occurred at regular 30-day intervals and lasted for 5 days. She has not had vaginal pain or discharge, headache... | Determination of serum thyroid-stimulating hormone and prolactin concentrations | CT scan of the pelvis | Endometrial biopsy | Hysteroscopy with dilatation and curettage | Trial of hormone replacement therapy | null | null | null | null | null | C | Endometrial biopsy | Text | STEP 3 | 0.88 | 97.36 | hard | 10 | C | A | C | medium |
139 | A 12-year-old boy is brought to the physician by his mother because of a 1-month history of pain below the left knee. His mother says, "He can usually walk around, but he hasn't been able to play in any of his soccer games since this all began." Examination of the left knee shows warmth, swelling, and tenderness. An x-... | Anterior cruciate ligament | Gastrocnemius muscle | Patellar ligament | Popliteus muscle | Posterior cruciate ligament | Soleus muscle | null | null | null | null | C | Patellar ligament | PIX | STEP 1 | 0.64 | 88.2 | hard | 11 | C | D | D | hard |
129 | Three weeks ago a 45-year-old man was admitted to the hospital because of frostbite of both feet. He was treated by rapid rewarming and protective care of the feet. All the toes on the right foot have turned black. He has become slightly febrile and progressively more confused during the past few days. Examination disc... | Amputation | Application of topical collagenase | Debridement of necrotic skin over the toes | Hyperbaric oxygen | Whirlpool therapy | null | null | null | null | null | A | Amputation | Text | STEP 3 | 0.54 | 49.42 | medium | 12 | A | C | C | hard |
89 | A study is designed to evaluate the feasibility of acupuncture in children with chronic headaches. Sixty children with chronic headaches are recruited for the study. In addition to their usual therapy, all children are treated with acupuncture three times a week for 2 months. Which of the following best describes this ... | Case-control | Case series | Crossover | Cross-sectional | Historical cohort | Randomized clinical trial | null | null | null | null | B | Case series | Text | STEP 1 | 0.84 | 79.34 | hard | 13 | C | B | B | medium |
532 | A 37-year-old woman comes to the office for a follow-up examination 3 weeks after testing confirmed a mass in her left breast to be benign. She says that despite the test results, she has had anxiety, insomnia, and a preoccupation with cancer since noticing the lump. Two weeks ago, she had a 20-minute episode of marked... | Avoidant personality disorder | Generalized anxiety disorder | Illness anxiety disorder (hypochondriasis) | Persistent depressive disorder (dysthymia) | Social anxiety disorder (social phobia) | null | null | null | null | null | B | Generalized anxiety disorder | Text | STEP 2 | 0.54 | 81.02 | medium | 14 | C | B | C | hard |
502 | A 46-year-old woman with active ankylosing spondylitis comes to the office for a follow-up examination. The use of various conventional nonsteroidal anti-inflammatory drugs has been ineffective. Sulfasalazine treatment also has not resulted in improvement. The most appropriate next step in treatment is administration o... | CD20 | Cyclooxygenase-2 | Cytotoxic T-lymphocyte antigen 4 | Epidermal growth factor | Interleukin-1 (IL-1) | Tumor necrosis factor α | null | null | null | null | F | Tumor necrosis factor α | Text | STEP 1 | 0.3 | 64.72 | medium | 15 | F | F | F | easy |
85 | A 52-year-old man comes to the physician with his wife because of a 1-year history of excessive daytime sleepiness. He does not think the symptoms are problematic, but his wife is concerned because he sometimes falls asleep on the sofa early in the evening when guests are present. He also once fell asleep while drivi... | 24-Hour ambulatory ECG monitoring | Multiple sleep latency test | Polysomnography | CT scan of the head | Laryngoscopy | null | null | null | null | null | C | Polysomnography | Text | STEP 2 | 0.08 | 46.29 | easy | 16 | C | C | C | easy |
36 | A 54-year-old woman is in the out-patient surgery center for biopsy of a cervical lymph node, which was ordered because of progressive adenopathy. She was given lidocaine infiltration and heavy intravenous sedation. A left node biopsy was attempted, but when diagnostic tissue was not obtained, a right node biopsy was d... | The sensation is probably due to the lidocaine spreading through the subcutaneous tissue and that she can be discharged home | This is a life-threatening clostridial infection; antibiotic therapy and an emergency operation will be arranged | This is a routine problem after surgical incisions and tissue dissection to obtain biopsy material | This is probably due to the volume of intravenous fluid she has received; you will give her a dose of furosemide and discharge her home | This may be due to pleural puncture; she should be admitted to the hospital for observation | null | null | null | null | null | E | This may be due to pleural puncture; she should be admitted to the hospital for observation | PIX | STEP 3 | 0.5 | 107.1 | medium | 17 | B | B | E | hard |
272 | A previously healthy 40-year-old woman is brought to the emergency department by her husband because of a 2-day history of fever, lethargy, and confusion. Her temperature is 38°C (100.4°F), pulse is 80/min, respirations are 18/min, and blood pressure is 140/90 mm Hg. Physical examination shows scattered petechiae and e... | Acute myeloid leukemia | Autoimmune hemolytic anemia | Thrombotic thrombocytopenic purpura | Toxic shock syndrome | von Willebrand disease | null | null | null | null | null | C | Thrombotic thrombocytopenic purpura | Text | STEP 1 | 0.18 | 135.35 | easy | 18 | C | C | C | easy |
346 | A 65-year-old woman comes to the physician for a follow-up examination after blood pressure measurements were 175/105 mm Hg and 185/110 mm Hg 1 and 3 weeks ago, respectively. She has well-controlled type 2 diabetes mellitus. Her blood pressure now is 175/110 mm Hg. Physical examination shows no other abnormalities. Ant... | Atherosclerosis | Congenital renal artery hypoplasia | Fibromuscular dysplasia | Takayasu arteritis | Temporal arteritis | null | null | null | null | null | A | Atherosclerosis | Text | STEP 1 | 0.6 | 87.78 | hard | 19 | A | C | A | medium |
273 | A 42-year-old woman comes to the physician for a routine examination. She says that she has felt well except for occasional episodes of constipation, abdominal discomfort, and mild fatigue. She was treated for a renal calculus 10 years ago and was told she had a "lazy gallbladder." Her pulse is 82/min, and blood pressu... | Adrenal gland | Anterior pituitary gland | Gallbladder | Kidney | Parathyroid gland | Thymus | null | null | null | null | E | Parathyroid gland | Text | STEP 1 | 0.24 | 157.58 | easy | 20 | E | E | E | easy |
239 | A 45-year-old man comes to the office because of severe pain of the right foot that awoke him from sleep last night. He says the pain kept him awake for the rest of the night. Walking has been difficult due to the pain, which he rates as a 9 on a 10-point scale. He reports no recent trauma. Medical history is remarkabl... | Acetaminophen | Allopurinol | Ceftriaxone | Indomethacin | Vancomycin | null | null | null | null | null | D | Indomethacin | Text | STEP 3 | 0.3 | 93.92 | medium | 21 | C | D | C | hard |
547 | A 50-year-old man comes to the office because of a 2-month history of increasing daytime somnolence. He has obstructive sleep apnea for which he has only intermittently used a continuous positive airway pressure device. He is 170 cm (5 ft 7 in) tall and weighs 181 kg (400 lb); BMI is 63 kg/m2. His temperature is 37°C (... | Decreased serum bicarbonate concentration | Increased hemoglobin concentration | Increased total lung capacity | Left ventricular hypertrophy | null | null | null | null | null | null | B | Increased hemoglobin concentration | Text | STEP 1 | 0.36 | 107.04 | medium | 22 | B | A | D | hard |
571 | A 25-year-old woman comes to the office because of a 6-month history of increasingly severe low back pain and heavy menses. Her temperature is 37.1°C (98.8°F), pulse is 75/min, respirations are 13/min, and blood pressure is 115/79 mm Hg. Physical examination shows no abnormalities. An endometrial biopsy specimen shows ... | AMP-dependent kinases | Cyclin-dependent kinases | Hexokinases | Lipid kinases | Urokinases | null | null | null | null | null | B | Cyclin-dependent kinases | Text | STEP 1 | 0.2 | 75.3 | easy | 23 | B | B | B | easy |
177 | A 67-year-old man is brought to the emergency department because of a 1-week history of nausea, generalized weakness, and malaise. He has congestive heart failure, hypertension, and coronary artery disease. Current medications include lisinopril, digoxin, isosorbide, spironolactone, and metoprolol. His temperature is 3... | Adverse effect of medications | Laboratory error | Metabolic acidosis | Renal failure | Rhabdomyolysis | null | null | null | null | null | A | Adverse effect of medications | Text | STEP 2 | 0.62 | 111.73 | hard | 24 | A | D | A | medium |
444 | A new diagnostic test for HIV infection is developed. The new serum biomarker concentration is measured in 711 men and women, ages 25 to 65 years. Of these individuals, 336 were previously determined to have HIV and 375 do not have HIV. Stratified results of the new serum biomarker test are shown: New Serum Biomarker N... | 2 | 8 | 13 | 25 | 33 | null | null | null | null | null | C | 13 | Text | STEP 3 | 0.9 | 229.43 | hard | 25 | D | B | B | hard |
284 | A 32-year-old woman comes to the emergency department because of a 3-day history of worsening fever, dry cough, and shortness of breath. She also has had abdominal discomfort, diarrhea, and nausea, but she has not vomited. She returned home from a business trip to a midwestern city 2 days ago. She has had no known cont... | Cefuroxime alone | Cefuroxime and azithromycin | Levofloxacin alone | Levofloxacin and ticarcillin | Piperacillin-tazobactam | null | null | null | null | null | B | Cefuroxime and azithromycin | Text | STEP 3 | 0.84 | 149.36 | hard | 26 | B | C | E | hard |
130 | A 52-year-old woman comes to the emergency department because of a 1-week history of low-grade fever and increasing abdominal cramps that are exacerbated by bowel movements. She began a course of amoxicillin-clavulanate and metronidazole 2 days ago but has had no relief of her symptoms. She has had intermittent constip... | Examination of the stool for ova and parasites | Test of the stool for Clostridium difficile toxin | Endoscopic retrograde cholangiopancreatography | Pelvic ultrasonography | CT scan of the abdomen with contrast | Colonoscopy | null | null | null | null | E | CT scan of the abdomen with contrast | Text | STEP 2 | 1 | 149.51 | hard | 27 | E | B | E | medium |
237 | An 18-year-old woman with sickle cell disease is brought to the emergency department by her parents because of a 2-hour history of severe abdominal pain and nausea. Her parents say that she had a cheeseburger, milk shake, and chocolate bar for lunch. Her temperature is 37°C (98.6°F). Physical examination shows tenderne... | Decreased hepatic secretion of lecithin | Decreased reabsorption of bile salts | High ratio of cholesterol to bile acids in bile | Infestation with parasites secreting β-glucuronidase | Overload of unconjugated bilirubin | null | null | null | null | null | E | Overload of unconjugated bilirubin | Text | STEP 1 | 0.68 | 87.96 | hard | 28 | C | B | C | hard |
156 | A 72-year-old woman with advanced ovarian cancer metastatic to the liver is brought to the physician by her son because she cries all the time and will not get out of bed. On a 10-point scale, she rates the pain as a 1 to 2. She also has hypertension and major depressive disorder. She has received chemotherapy for 2 ye... | Reassurance | Assess for suicidal ideation | Begin dextroamphetamine therapy | Increase oxycodone dosage | Restart chemotherapy | null | null | null | null | null | B | Assess for suicidal ideation | Text | STEP 2 | 0.08 | 64.66 | easy | 29 | B | B | B | easy |
58 | A 37-year-old woman, gravida 5, para 4, at 34 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours. She has had no prenatal care. Her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other three children were... | Abruptio placentae | Amniotic fluid embolism | Latent phase of labor | Placenta previa | Ruptured uterus | Ruptured vasa previa | null | null | null | null | D | Placenta previa | Text | STEP 2 | 0.36 | 80.64 | medium | 30 | D | D | D | easy |
31 | A new test has been developed to detect the presence of a tumor-specific protein in serum. The initial evaluation of this test shows: Tumor Present Absent Test Result Positive 40 20 60 Negative 10 30 40 50 50 100Which of the following is the likelihood that a patient with a positive test from this samp... | 0.25 | 0.33 | 0.67 | 0.75 | 0.80 | null | null | null | null | null | C | 0.67 | Text | STEP 1 | 0.1 | 67.9 | easy | 31 | C | C | C | easy |
234 | A 45-year-old woman comes to the office because she has noticed during the past several months that her fingernails have become white, increasingly brittle, and seem to lift off her nail beds easily. During this time, she also has had episodes of feeling warm and perspiring. Medical history is remarkable for intravenou... | Chronic obstructive pulmonary disease | Diabetes mellitus | Endocarditis | Hyperthyroidism | Perimenopause | null | null | null | null | null | D | Hyperthyroidism | Text | STEP 3 | 0.26 | 68.78 | easy | 32 | D | D | D | easy |
481 | A 5-year-old girl is brought to the office by her mother because of a 6-hour history of bloody diarrhea. She is interactive and in no acute distress. Her blood pressure is 90/55 mm Hg. Abdominal examination shows normoactive bowel sounds. Stool cultures are obtained, and the patient's mother is advised to give the girl... | Campylobacter jejuni | Escherichia coli | Rotavirus | Salmonella enterica serovar enteritidis | Yersinia pestis | null | null | null | null | null | B | Escherichia coli | Text | STEP 1 | 0.12 | 71.45 | easy | 33 | B | B | D | medium |
316 | A 27-year-old man comes to the physician because of a 1-month history of progressive fatigue and episodes of moderate abdominal pain. He has a 4-year history of recurrent nosebleeds that have increased in frequency despite undergoing cauterization of the nasal mucosa 6 months ago. He takes no medications. His sister ha... | Bernard-Soulier syndrome | Glanzmann thrombasthenia | Hemophilia A | Hereditary hemorrhagic telangiectasia | von Willebrand disease | null | null | null | null | null | E | von Willebrand disease | Text | STEP 2 | 0.5 | 107.84 | medium | 34 | T | E | D | hard |
428 | A 17-year-old girl is brought to the physician by her mother because she has not had a menstrual period for 6 months. The patient is unconcerned about the lack of menses. Menarche occurred at the age of 12 years, and menses had occurred at regular 28-day intervals until they became irregular 1 year ago. She is a member... | Hyperthyroidism | Hypogonadotropic hypogonadism | Hypothyroidism | Polycystic ovary syndrome | Prolactinoma | null | null | null | null | null | B | Hypogonadotropic hypogonadism | Text | STEP 1 | 0.1 | 51.34 | easy | 35 | B | B | B | easy |
591 | A 68-year-old woman with end-stage renal disease comes to the office for a follow-up examination. She has required hemodialysis for the past year. Initially, she did well, but within the past 3 months, she has been admitted to the hospital for fluid overload because of poor adherence to fluid and salt restrictions. She... | "I imagine being on dialysis is frustrating, but you don't want to die from kidney disease, do you?" | "I know that this is challenging, but do you remember how difficult it is to be hospitalized?" | "It is tough to change your diet and fluid intake, but what sorts of things were you doing at first when you were following the recommendations?" | "Making these changes is so difficult. Can you imagine how good you will feel once you make the changes again?" | "This is very hard to do, but you may have an easier time if you met with the dietician again." | null | null | null | null | null | C | "It is tough to change your diet and fluid intake, but what sorts of things were you doing at first when you were following the recommendations?" | Text | STEP 1 | 0.16 | 64.18 | easy | 36 | C | C | E | medium |
46 | A 65-year-old woman has a 6-month history of progressive irritability, palpitations, heat intolerance, frequent bowel movements, and a 6.8-kg (15-lb) weight loss. She has had a neck mass for more than 10 years. 131I scan shows an enlarged thyroid gland with multiple areas of increased and decreased uptake. Which of the... | Defect in thyroxine (T4) biosynthesis | Graves' disease | Multinodular goiter | Riedel's thyroiditis | Thyroid carcinoma | Thyroiditis | Toxic adenoma | Triiodothyronine (T3) thyrotoxicosis | null | null | C | Multinodular goiter | Text | STEP 2 | 0.5 | 65.54 | medium | 37 | C | C | C | easy |
313 | A 44-year-old man comes to the physician because of a 6-week history of progressive numbness of his feet. Two months ago, he completed a course of chemotherapy, including vincristine, for small cell lung carcinoma. Physical examination shows muscle weakness of the distal portion of the feet and absent ankle jerk reflex... | Apoptosis of dorsal root ganglion neurons | Blockade of mitochondrial respiratory chain | Decreased expression of myelin protein in Schwann cells | Depolymerization of microtubules | Inhibition of synaptic vesicle endocytosis | null | null | null | null | null | D | Depolymerization of microtubules | Text | STEP 1 | 0.1 | 56.91 | easy | 38 | D | D | D | easy |
605 | A 72-year-old woman is evaluated in the acute rehabilitation facility where she has been receiving physical therapy since sustaining a stroke 2 weeks ago that resulted in moderate left hemiparesis. A swallowing study obtained on admission to the facility showed no abnormalities and she has been progressing well with he... | Discharge the patient with a plan for home health care and physical therapy | Inform the patient that she would need to sign out against medical advice | Inform the patient that transfer to a long-term care facility is most suitable for her | Request psychiatric evaluation of the patient's decision-making capacity | null | null | null | null | null | null | A | Discharge the patient with a plan for home health care and physical therapy | Text | STEP 2 | 0.58 | 104.1 | medium | 39 | B | D | D | hard |
611 | A 5-year-old boy is brought to the office by his mother because of a 2-week history of intermittent bloody stools. He is otherwise asymptomatic. He has no history of major medical illness and receives no medications. He does not appear to be in distress. Vital signs are within normal limits. Physical examination shows ... | Adenocarcinoma | Carcinoid tumor | Hamartomatous polyp | Hyperplastic polyp | Inflammatory polyp | Tubular adenoma | null | null | null | null | C | Hamartomatous polyp | PIX | STEP 1 | 0.9 | 111.47 | hard | 40 | C | C | C | easy |
191 | A 55-year-old woman is brought to the office by her husband because of increasingly severe pain in her mid back for the past week. She says the pain is especially severe with walking. Her husband says she has been favoring her right leg for the past 3 days. Ibuprofen no longer controls the pain. She enjoys gardening bu... | Acetaminophen-oxycodone therapy and referral for physical therapy | Admission to the hospital for pain control | Electromyography and nerve conduction studies | MRI of the thoracic spine | Technetium 99m scan | null | null | null | null | null | D | MRI of the thoracic spine | Text | STEP 3 | 0.16 | 93.11 | easy | 41 | D | D | D | easy |
201 | A 70-year-old man is brought to the emergency department by his son because of a 2-day history of right upper quadrant abdominal pain, chills, and confusion. He has vomited twice during this time despite decreased food intake. The patient has hypertension controlled with hydrochlorothiazide. Medical and surgical histor... | Acute cholecystitis | Acute pancreatitis | Cholangitis | Hepatitis | Liver abscess | null | null | null | null | null | C | Cholangitis | Text | STEP 3 | 0.9 | 114.8 | hard | 42 | C | C | C | easy |
387 | A 27-year-old primigravid woman comes to the physician for her first prenatal visit 10 weeks after a home pregnancy test was positive. She feels well, and her pregnancy has been uncomplicated. She previously used an oral contraceptive but discontinued it 3 months ago. She has no history of sexually transmitted diseases... | Bacterial vaginosis | Cytomegalovirus | Epstein-Barr virus | HIV | Human papillomavirus | null | null | null | null | null | D | HIV | Text | STEP 2 | 0.12 | 51.37 | easy | 43 | D | C | D | medium |
522 | A 25-year-old woman is admitted to the hospital because of a 2-day history of fever, dizziness, light-headedness, chills, and shaking. She has hyperthyroidism, gastroesophageal reflux disease, and asthma. Her medications are oral methimazole and omeprazole, and inhaled fluticasone, and she has been on the same dosages ... | Atovaquone-proguanil | Fluticasone | Hepatitis A vaccine | Methimazole | Omeprazole | Yellow fever vaccine | null | null | null | null | D | Methimazole | Text | STEP 2 | 0.7 | 93.18 | hard | 44 | F | C | A | hard |
83 | A 42-year-old woman comes to the physician because of an 8-week history of intermittent nausea and abdominal pain that occurs 20 to 30 minutes after eating. The pain extends from the epigastrium to the right upper quadrant and is sometimes felt in the right scapula; it lasts about 30 minutes and is not relieved by ant... | Abdominal ultrasonography of the right upper quadrant | Upper gastrointestinal series with small bowel follow-through | CT scan of the abdomen | Endoscopic retrograde cholangiopancreatography | Elective cholecystectomy | Immediate cholecystectomy | null | null | null | null | A | Abdominal ultrasonography of the right upper quadrant | Text | STEP 2 | 0.1 | 53.21 | easy | 45 | A | A | A | easy |
525 | A 60-year-old woman comes to the office as a new patient. She recently moved to the area. She feels well. She has hypertension treated with amlodipine and asthma well controlled with inhaled fluticasone and inhaled albuterol as needed. According to the medical records she brought with her, a mammography 6 months ago sh... | Abdominal aortic aneurysm | Breast cancer | Chlamydia trachomatis infection | Colon cancer | Hepatitis C | null | null | null | null | null | E | Hepatitis C | Text | STEP 2 | 0.36 | 99.75 | medium | 46 | E | C | B | hard |
204 | A 72-year-old woman comes to the physician because of a 2-month history of painless swelling of both ankles. She also reports shortness of breath with exertion and when lying down. She has been awakened from sleep by shortness of breath. She has not had chest pain. Her pulse is 96/min and regular, respirations are 24/m... | Measurement of serum troponin I concentration | ECG | Exercise stress test | Echocardiography | Pulmonary artery catheterization | null | null | null | null | null | D | Echocardiography | Text | STEP 1 | 0.44 | 94.75 | medium | 47 | D | D | D | easy |
134 | A 37-year-old woman with AIDS comes to the physician because of a 1-month history of progressive diarrhea and a 1.8-kg (4-lb) weight loss. During the past week, she has had six large watery stools daily. She is currently receiving triple antiretroviral therapy. She is employed as a flight attendant and works regularly ... | Cryptosporidium parvum | Cytomegalovirus | Mycobacterium avium-intracellulare complex | Salmonella enteritidis | Strongyloides stercoralis | null | null | null | null | null | A | Cryptosporidium parvum | Text | STEP 2 | 0.54 | 68.47 | medium | 48 | A | A | E | medium |
353 | A 24-year-old woman, gravida 1, para 1, comes to the office because she and her husband have been trying to conceive for the past year without success. She gave birth to her first child at age 18 years by cesarean delivery following fetal distress. She then developed postpartum endometritis that resolved with intraveno... | Bacterial vaginosis | Cesarean delivery | Chlamydial cervicitis | Postpartum endometritis | Use of an IUD | null | null | null | null | null | C | Chlamydial cervicitis | Text | STEP 3 | 0.6 | 74.76 | hard | 49 | C | B | D | hard |
306 | A 45-year-old woman with a history of seizure disorder comes to the office because she has had seizures daily for the past 3 weeks, despite adhering to her medication regimen. Medical history is also significant for borderline hypertension for the past year and alcohol use disorder. She admits that she has been drinkin... | Discussing a new treatment regimen for the patient's seizure disorders | Evaluating the patient for depressive disorder | Evaluating the patient's ability/desire to stop drinking alcoholic beverages | Instructing the patient to stop driving | null | null | null | null | null | null | D | Instructing the patient to stop driving | Text | STEP 3 | 0.32 | 74.32 | medium | 50 | D | C | C | hard |
355 | A 5-week-old infant is brought to the office by his mother for an initial well-child visit. He was born at 37 weeks' gestation via cesarean delivery because of chorioamnionitis. The infant had fetal distress that was documented by fetal monitoring during labor. The mother became jaundiced in the immediate postpartum pe... | All factors appeared to have an effect on HCV transmission | Fetal electrode monitoring was protective against HCV | Infant HIV infection was the only significantly associated factor | Maternal chorioamnionitis was the most significantly associated factor | No factor was significantly associated | null | null | null | null | null | C | Infant HIV infection was the only significantly associated factor | Text | STEP 3 | 0.1 | 92.49 | easy | 51 | C | A | D | hard |
388 | A 54-year-old woman comes to the emergency department because of severe jaw pain since undergoing a painful dental procedure 1 day ago. The patient was prescribed codeine after the procedure and instructed to take the medication every 4 hours, but she has continued pain despite adherence to this analgesic regimen. Othe... | Decreased absorption of codeine | Decreased metabolism of codeine to morphine | Deficiency of κ receptors | Increased plasma protein-binding of codeine | Increased renal clearance of codeine | null | null | null | null | null | B | Decreased metabolism of codeine to morphine | Text | STEP 1 | 0.44 | 71.87 | medium | 52 | B | B | B | easy |
20 | A sexually active 20-year-old woman has had fever, chills, malaise, and pain of the vulva for 2 days. Examination shows a vulvar pustule that has ulcerated and formed multiple satellite lesions. Nodes are palpated in the inguinal and femoral areas. A smear of fluid from the lesions establishes the diagnosis. Which of t... | Chlamydia trachomatis | Haemophilus ducreyi | Neisseria gonorrhoeae | Streptococcus pyogenes (group A) | Treponema pallidum | null | null | null | null | null | B | Haemophilus ducreyi | Text | STEP 2 | 0.44 | 66.84 | medium | 53 | B | B | B | easy |
614 | A 57-year-old man is admitted to the hospital 30 minutes after he was found wandering in the streets. Fingerstick blood glucose concentration obtained by paramedics prior to transport was 68 mg/dL. The patient's medical history is unknown. Temperature is 35.8°C (96.5°F), pulse is 80/min, respirations are 16/min, and bl... | Glucose | Vitamin B1 (thiamine) | Vitamin B2 (riboflavin) | Vitamin B6 (pyridoxine) | Vitamin B12 (cyanocobalamin) | null | null | null | null | null | B | Vitamin B1 (thiamine) | Text | STEP 2 | 0.16 | 50.01 | easy | 54 | B | B | B | easy |
460 | A 70-year-old woman comes to the office because of a 1-month history of gradually worsening shortness of breath. Medical history is significant for hypertension and hyperlipidemia. Routine medications are atorvastatin and lisinopril. The patient appears to be in respiratory distress. Vital signs are temperature 36.7°C ... | Bone marrow biopsy | Pericardiocentesis | Pleurodesis | Thoracentesis | Video-assisted thoracoscopy | null | null | null | null | null | D | Thoracentesis | Text | STEP 3 | 0.1 | 76.4 | easy | 55 | D | D | D | easy |
480 | A 12-year-old girl is brought to the office because of a 2-day history of chest pain. She also had a 3-day history of fever that has since resolved. When she lies down, the pain worsens and she has shortness of breath. Her temperature is 37°C (98.6°F). A friction rub is heard. Which of the following is the most likely ... | Coxsackievirus | Mumps virus | Staphylococcus aureus | Staphylococcus epidermidis | Viridans streptococcus | null | null | null | null | null | A | Coxsackievirus | Text | STEP 1 | 0.12 | 53.51 | easy | 56 | A | A | A | easy |
604 | A 55-year-old woman is diagnosed with parathyroid adenoma after ultrasonography of the neck showed a soft-tissue, hypoechoic mass at the back of the left lobe of the thyroid bed. Surgical removal of the mass is planned, and the patient is admitted to the hospital. During this procedure, ligation of which of the followi... | Ascending pharyngeal artery | Costocervical trunk | Inferior thyroid artery | Internal thoracic artery | Transverse cervical artery | null | null | null | null | null | C | Inferior thyroid artery | Text | STEP 1 | 0.28 | 70.35 | easy | 57 | C | C | C | easy |
348 | A 23-year-old woman comes to the physician for genetic counseling prior to conception. Her brother and maternal uncle had Duchenne muscular dystrophy (DMD) and died at the ages of 28 and 17 years, respectively. Genetic analysis was not performed on either relative prior to death. Serum studies show a muscle creatine ki... | The patient has a 50% risk for developing DMD | The patient has a 50% risk of having a child with DMD | The patient is a carrier of the disease based on her family history of DMD | The patient is not a carrier of DMD based on her normal creatine kinase concentration | The patient's DMD carrier status is uncertain because of random X inactivation | null | null | null | null | null | E | The patient's DMD carrier status is uncertain because of random X inactivation | Text | STEP 1 | 1.24 | 155.24 | hard | 58 | C | E | C | hard |
503 | A 32-year-old man is brought to the emergency department 30 minutes after being struck by a car while driving his motorcycle. He reports severe pelvic pain. On examination, there is bruising of the perineum and pain is elicited with motion of his pelvis. Blood is noted at the urethral meatus. There is no other penile t... | Intramural (pre-prostatic) | Membranous | Prostatic | Spongy | null | null | null | null | null | null | B | Membranous | Text | STEP 1 | 0.42 | 63.68 | medium | 59 | B | B | D | medium |
471 | Five days after admission to the hospital for management of an ST-elevation myocardial infarction, a 59-year-old man has the sudden onset of severe abdominal and bilateral lower extremity pain, cyanosis of the lower body, and paresthesias. On hospital days 1 and 2, he received vasopressor and inotropic therapy. On hosp... | Aortic dissection | Aortic embolism | Pericardial tamponade | Right ventricular failure | Ventricular rupture | null | null | null | null | null | B | Aortic embolism | Text | STEP 2 | 1.38 | 160.72 | hard | 60 | B | D | E | hard |
435 | A 59-year-old man is brought to the emergency department because of a 4-day history of nausea, vomiting, and diarrhea. He also has been confused and agitated during this period. He has a history of mild hypertension. His current medication is a diuretic. His temperature is 37°C (98.6°F), pulse is 108/min, respirations ... | Cardiogenic | Distributive | Hypovolemic | Obstructive | Septic | null | null | null | null | null | C | Hypovolemic | Text | STEP 1 | 0.16 | 86.72 | easy | 61 | C | B | C | medium |
63 | A 14-year-old girl has had nausea, intermittent diarrhea, and a 2.2-kg (5-lb) weight loss over the past 4 weeks. Examination shows a migrating serpiginous pruritic perianal rash. Her leukocyte count is 8000/mm3 with 20% eosinophils. Which of the following tests is most likely to yield an accurate diagnosis? | Blood smear | Bone marrow biopsy | KOH preparation | Microscopic examination of the stool | Skin snip | null | null | null | null | null | D | Microscopic examination of the stool | Text | STEP 1 | 0.38 | 69.67 | medium | 62 | D | C | E | hard |
37 | A 62-year-old woman is brought to the emergency department because of obtundation. On physical examination, she has hypotension and tachycardia. Respirations are 24/min. She has cherry-red maculae on funduscopic examination. Results of initial laboratory studies are shown: Serum Urine Urea nitrogen 37 mg/dL Color... | Alcoholic ketoacidosis | Diabetic ketoacidosis | Isopropyl alcohol intoxication | Methanol intoxication | Salicylate intoxication | null | null | null | null | null | D | Methanol intoxication | Text | STEP 3 | 0.82 | 144.65 | hard | 63 | D | D | D | easy |
371 | A 56-year-old woman comes to the physician because of a 2-year history of recurrent urinary tract infections accompanied by left flank pain. Physical examination shows no abnormalities. Renal ultrasonography shows left-sided hydronephrosis. A T2-weighted coronal MRI of the abdomen is shown; the arrow indicates the hydr... | Bladder neck | Mid ureter | Renal calyx | Ureteropelvic junction | Ureterovesical junction | null | null | null | null | null | D | Ureteropelvic junction | PIX | STEP 1 | 0.52 | 84 | medium | 64 | D | D | D | easy |
264 | An experimental animal is created in which the germinal centers of the reactive lymph nodes show shrinkage of cells, cytoplasmic budding, no adjacent inflammation, and intact plasma membranes. These cellular findings are most likely caused by which of the following mechanisms? | Caspase activation | Decreased cytochrome c concentration | Decreased intracellular Ca2+ concentration | Increased glutathione peroxidase activity | Increased lysosomal enzyme activity | null | null | null | null | null | A | Caspase activation | Text | STEP 1 | 0.36 | 66.76 | medium | 65 | A | A | A | easy |
47 | A 4-year-old boy is brought for a follow-up examination. He has a history of chronic recurrent otitis media and recently completed a 10-day course of antibiotics. His vital signs are within normal limits. Examination shows clear ear canals and intact tympanic membranes; a brown, irregular mass is visualized behind t... | Epithelial tissue proliferation | Lingual papillae loss | Middle ear effusion | Midface hypoplasia | Nerve entrapment | Olfactory hair cell degeneration | Semicircular canal edema | Tympanic membrane rupture | null | null | A | Epithelial tissue proliferation | Text | STEP 2 | 0.74 | 73.62 | hard | 66 | A | A | C | medium |
563 | A 51-year-old man with a 10-year history of gastroesophageal reflux and suspected Barrett esophagus comes to the office because his omeprazole dose "doesn't work around the Christmas holidays." He states that he prides himself on having a large appetite and "holding his liquor" during the holidays. He currently takes t... | Ask the patient how much he is eating and drinking during the holidays | Explain the hazards of untreated reflux in the presence of Barrett esophagus | Order an upper endoscopy | Refer the patient to a gastroenterologist | Switch the omeprazole to pantoprazole | null | null | null | null | null | A | Ask the patient how much he is eating and drinking during the holidays | Text | STEP 1 | 0.28 | 63.1 | easy | 67 | C | B | A | hard |
274 | A placebo-controlled clinical trial is conducted to assess whether a new antihypertensive drug is more effective than standard therapy. A total of 5000 patients with essential hypertension are enrolled and randomly assigned to one of two groups: 2500 patients receive the new drug and 2500 patients receive placebo. If t... | Significant findings can be reported with greater confidence | The study will have more power | There is a decreased likelihood of a Type II error | There is an increased likelihood of statistically significant findings | There is an increased likelihood of a Type I error | null | null | null | null | null | A | Significant findings can be reported with greater confidence | Text | STEP 1 | 0.54 | 92.98 | medium | 68 | A | A | D | medium |
184 | A 37-year-old man with type 1 diabetes mellitus is admitted to the hospital because of inadequate control of his glucose concentrations for the past 2 months. Despite his poor control, he demands that he be discharged. He reports that he has had a 3-month history of fatigue, irritability, and feelings of hopelessness. ... | Adhere to the patient's wishes and discuss home-care options | Adhere to the patient's wishes on the condition that he agree to home nursing care | Schedule neuropsychological testing | Seek a court order to appoint a legal guardian | Involuntarily hold the patient in the hospital | null | null | null | null | null | A | Adhere to the patient's wishes and discuss home-care options | Text | STEP 2 | 0.84 | 111.48 | hard | 69 | E | E | E | hard |
200 | A 34-year-old woman comes to the office because of a 1-month history of worsening right upper quadrant abdominal pain and discomfort. She describes the pain as a dull ache and says it is not affected by eating or defecating. She has not had nausea or changes in appetite or bowel habits. She feels the pain constantly wh... | Hepatic adenoma | Hepatocellular cancer | Hydatid cyst | Metastatic ovarian cancer | null | null | null | null | null | null | A | Hepatic adenoma | Text | STEP 3 | 0.18 | 57.72 | easy | 70 | A | A | A | easy |
570 | A 47-year-old man comes to the office to establish care. He recently moved to the area and has not been evaluated by a physician for more than 3 years. He reports a 1-year history of bilateral knee pain that worsens after prolonged standing, but he otherwise has felt well. Medical history is unremarkable and his only m... | Prescribe atorvastatin | Prescribe cholestyramine | Recommend diet and low-impact exercise | Refer the patient to a cardiologist | Repeat fasting laboratory studies in 1 month | null | null | null | null | null | C | Recommend diet and low-impact exercise | Text | STEP 3 | 0.68 | 86.85 | hard | 71 | C | C | C | easy |
443 | A randomized controlled trial is conducted to assess the effectiveness of a new combination-drug antihypertensive therapy (Drug X) compared with a standard antihypertensive single-drug therapy. Study participants include 140 women (70%) and 60 men (30%) ages 30 to 60 years, with baseline blood pressure measurements of ... | 1% | 10% | 40% | 90% | 99% | null | null | null | null | null | D | 90% | Text | STEP 3 | 0.56 | 102.42 | medium | 72 | D | C | D | medium |
426 | A 19-year-old woman comes to her university's health center because of a 1-week history of nasal stuffiness, occasional clear rhinorrhea, and a mild sore throat. Two days ago, she began to feel hot, but she has not taken her temperature. Medical history is unremarkable and her only medication is an oral contraceptive. ... | Eustachian tube dysfunction | Mucosal edema | Nasal polyps | Oral contraceptive use | Tonsillar hyperplasia | null | null | null | null | null | B | Mucosal edema | Text | STEP 3 | 0.8 | 90.38 | hard | 73 | B | B | B | easy |
589 | A 50-year-old woman is brought to the emergency department because of a 3-day history of severely painful lesions over her right leg and temperatures to 38.7°C (101.7°F). She has a 12-year history of type 2 diabetes mellitus. Her only medication is insulin. On arrival, temperature is 39.3°C (102.8°F). Examination of th... | Cellulitis | Dermatophytosis | Erysipelas | Erythema nodosum | Herpes zoster | Necrotizing fasciitis | null | null | null | null | F | Necrotizing fasciitis | Text | STEP 2 | 0.56 | 85.61 | medium | 74 | F | F | F | easy |
244 | A 30-year-old woman, who has been a patient in the practice for several years, comes to the office to ask for advice. Her husband has a family history of retinitis pigmentosa and she wants to know the probability of her 4-year-old son developing the disease. A family pedigree is shown. Which of the following is the mos... | A geneticist should be consulted to answer her question | Her son must be tested to determine if he is affected | Her son will not be affected | She does not need to know, since there is nothing she can do if her son does have the condition | There is a 100% chance that her son will be affected | null | null | null | null | null | C | Her son will not be affected | PIX | STEP 3 | 0.42 | 113.2 | medium | 75 | A | A | A | hard |
271 | A 24-year-old woman comes to the physician for a follow-up examination. One week ago, she was treated in the emergency department after she accidentally spilled hot grease on her left leg while working at a fast-food restaurant. Examination of the left lower extremity shows a 7-cm, pink, soft, granular, edematous wound... | Complement C3b | Glycosylation-dependent cell adhesion molecule-1 | P-selectin | Stromelysin | Vascular endothelial growth factor | null | null | null | null | null | E | Vascular endothelial growth factor | Text | STEP 1 | 0.46 | 64.4 | medium | 76 | E | A | E | medium |
416 | A previously healthy 65-year-old woman comes to the physician because of several episodes of fainting during the past 2 months. Each episode lasted several minutes. Her pulse is 82/min, respirations are 20/min, and blood pressure is 135/87 mm Hg. Cardiac examination shows S3 and S4. Echocardiography shows a pedunculate... | Interventricular septum | Left atrium | Left ventricle | Right atrium | Right ventricle | null | null | null | null | null | B | Left atrium | PIX | STEP 1 | 0.22 | 45.49 | easy | 77 | B | A | B | medium |
530 | A 2-month-old girl is brought to the office by her mother for a routine examination. Newborn screening electrophoresis showed hemoglobin FS. The mother says her daughter has not had fever or pallor. The patient is feeding well and gaining weight appropriately. She receives no medications. She appears well. She is at th... | Amoxicillin as needed for febrile illness | Instructions for the parents to palpate the long bones routinely | Instructions for the parents to take and record the patient’s pulse daily | Low-dose aspirin therapy | Oral prophylactic penicillin therapy | null | null | null | null | null | E | Oral prophylactic penicillin therapy | Text | STEP 2 | 0.42 | 68.81 | medium | 78 | E | E | E | easy |
379 | A 3800-g (8-lb 6-oz) newborn is delivered vaginally at 39 weeks' gestation after an uncomplicated pregnancy. Apgar scores are 9 and 9 at 1 and 5 minutes, respectively. The newborn is crying, has pink skin, and appears vigorous. Physical examination shows a vagina and also a structure that appears to be a penis, with th... | 17α-Hydroxyprogesterone deficiency | Increased concentration of müllerian-inhibiting substance | Maternal androgen exposure | Presence of the sex-determining region Y gene | 5α-Reductase deficiency | null | null | null | null | null | C | Maternal androgen exposure | Text | STEP 1 | 0.5 | 116.33 | medium | 79 | E | A | C | hard |
536 | A 13-month-old boy is brought to a small rural emergency department (ED) near his family's community because of an erythematous, edematous mass in his perianal area that is hot to touch. He has no history of serious illness and receives no medications. Growth and development are appropriate for age. Vaccinations are up... | The patient received appropriate care under the circumstances | The pediatric surgeon at the suburban hospital should have insisted on personally examining the patient and draining the abscess | The rural hospital should have sent the patient directly to the downtown university hospital | The suburban hospital executed unethical but legal conduct in this case | The suburban hospital violated the Emergency Medical Treatment and Active Labor Act (EMTALA) | null | null | null | null | null | E | The suburban hospital violated the Emergency Medical Treatment and Active Labor Act (EMTALA) | Text | STEP 2 | 0.82 | 132.29 | hard | 80 | E | E | E | easy |
474 | A 17-year-old girl is brought to the physician by her parents because they are concerned she is using illicit drugs. They report that, “she just isn’t herself anymore.” She has no history of serious illness and takes no medications. She is upset about being “tricked” to come to the doctor. Physical examination shows no... | Comply with the parents’ wishes | Inform the parents that everything the patient tells the physician is confidential | Inform the parents that if the patient’s toxicology screening is positive, it must be reported to the police | Inform the parents that the physician cannot deceive the patient | null | null | null | null | null | null | D | Inform the parents that the physician cannot deceive the patient | Text | STEP 2 | 0.18 | 55.27 | easy | 81 | D | D | D | easy |
99 | A 21-year-old woman comes to the physician for preconceptional advice. She is recently married and would like to conceive within the next year. She does not eat meat, fish, or dairy products and wishes to decrease the risks of her diet on her baby. Menses occur at regular 28-day intervals and last 5 days. She does not ... | Adjusting diet to include more sources of protein during the first trimester | Beginning folic acid supplementation prior to conception | Calcium supplementation during the first trimester | Iron supplementation during the first trimester | Soy protein shakes throughout pregnancy and lactation | null | null | null | null | null | B | Beginning folic acid supplementation prior to conception | Text | STEP 2 | 0.08 | 50.83 | easy | 82 | B | B | B | easy |
38 | A 27-year-old man comes to the office with his wife because of a recent episode of loss of muscle control. He says, "I was at a reception, someone told a joke, and when I laughed, my legs collapsed!" His wife says that he recovered in a few seconds and he did not lose consciousness. He has a long history of sleepiness ... | Narcolepsy | Primary hypersomnia | A seizure disorder | Sleep paralysis | Vasovagal syndrome | null | null | null | null | null | A | Narcolepsy | Text | STEP 3 | 0.82 | 76.39 | hard | 83 | A | A | A | easy |
186 | An 18-month-old boy is brought to the emergency department by his parents 2 hours after swallowing a dime. The parents note that the child has not had any choking, respiratory problems, feeding problems, or vomiting since the incident. Medical history is unremarkable and the child is up-to-date on vaccinations. He does... | Administration of an oral bowel-cleansing solution | Endoscopic retrieval of the coin | Interventional radiologic retrieval of the coin | Surgical exploration of the stomach with coin retrieval | Observation only | null | null | null | null | null | E | Observation only | PIX | STEP 3 | 0.14 | 44.15 | easy | 84 | E | E | E | easy |
96 | A 47-year-old man is brought to the emergency department 2 hours after the sudden onset of shortness of breath, severe chest pain, and sweating. He has no history of similar symptoms. He has hypertension treated with hydrochlorothiazide. He has smoked one pack of cigarettes daily for 30 years. His pulse is 110/min,... | Acute myocardial infarction | Aortic dissection | Esophageal rupture | Mitral valve prolapse | Pulmonary embolism | null | null | null | null | null | B | Aortic dissection | Text | STEP 2 | 0.78 | 120.08 | hard | 85 | B | B | B | easy |
66 | A 63-year-old woman with hypertension has her son call your office to make an appointment for evaluation of vaginal bleeding. Her general physician recently retired. The son tells you that his mother has been deaf since infancy and that he uses sign language to communicate with her. Which of the following is the most a... | Have the patient bring her son to the appointment to interpret | Arrange for a certified interpreter | Provide the patient with writing materials during the appointment | Talk with the patient face-to-face, enunciating carefully so that she may lip read | Obtain a history via a telecommunication device for the deaf before the appointment | null | null | null | null | null | B | Arrange for a certified interpreter | Text | STEP 3 | 0.02 | 36.53 | easy | 86 | B | B | B | easy |
15 | A 4-year-old boy is brought to the physician because of temperatures to 39.4°C (102.9°F) for 8 days. Examination shows anterior cervical lymphadenopathy, nonexudative conjunctivitis bilaterally, a strawberry tongue, an erythematous truncal rash, and edema of the hands and feet. Which of the following is the most appr... | Intravenous immune globulin | Intravenous penicillin | Intravenous prednisone | Oral isoniazid | Oral rifampin | null | null | null | null | null | A | Intravenous immune globulin | Text | STEP 2 | 0.6 | 55.5 | hard | 87 | A | A | A | easy |
218 | A 41-year-old woman is brought to the emergency department by her husband because of nausea and dizziness that began suddenly 4 hours ago. She says she feels like the room is spinning. She has not vomited. She recalls receiving a blow to the left side of her neck 1 week ago when her dog jumped on her, but she has had n... | Parasympathetic overactivity | Parasympathetic underactivity | Postsynaptic neuromuscular junction defect | Presynaptic neuromuscular junction defect | Sympathetic overactivity | Sympathetic underactivity | null | null | null | null | F | Sympathetic underactivity | Text | STEP 3 | 0.78 | 113 | hard | 88 | F | F | F | easy |
193 | A technician wants to determine whether cytomegalovirus (CMV) DNA is present in the blood of a bone marrow transplant recipient. DNA purified from the leukocytes of the patient is reacted in a mixture containing oligonucleotides specific for CMV DNA, thermostable DNA polymerase, and nucleotides. Repetitive cycles of he... | Northern blotting | Polymerase chain reaction | Reverse transcription | Southern blotting | Western blotting | null | null | null | null | null | B | Polymerase chain reaction | Text | STEP 1 | 0.3 | 53.27 | medium | 89 | B | B | B | easy |
580 | A 32-year-old man is brought to the emergency department after being found by his wife in their bedroom with a gun in his hands. His wife reports that the patient “has not been himself” since their son was stillborn 6 months ago. She says that during the past month, he hardly has slept and has not showered or shaved; h... | Electroconvulsive therapy | Imipramine therapy | Mirtazapine therapy | Sertraline therapy | Transcranial magnetic stimulation | null | null | null | null | null | A | Electroconvulsive therapy | Text | STEP 2 | 0.54 | 69.99 | medium | 90 | C | A | C | hard |
172 | Two days after admission to the hospital for congestive heart failure, an 82-year-old man is unable to walk because of severe, throbbing pain in his left foot. He has no history of similar episodes or recent trauma. He also has coronary artery disease and hypertension. Current medications include atenolol, lisinopril, ... | 100 needle-shaped no organisms | 100 none gram-positive cocci | 100 none no organisms | 100 rhomboid no organisms | 20,000 needle-shaped no organisms | 20,000 none gram-positive cocci | null | null | null | null | E | 20,000 needle-shaped no organisms | Text | STEP 2 | 1.26 | 114.23 | hard | 91 | C | A | E | hard |
637 | A 55-year-old man comes to the emergency department because of a 6-hour history of diffuse abdominal pain and subjective fever. His most recent bowel movement 4 hours ago was loose but not bloody. He reports no chills or urinary symptoms. Medical history is remarkable for gastroesophageal reflux disease and alcoholic c... | Cefotaxime | Clindamycin | Metronidazole | Oxacillin | Vancomycin | No pharmacotherapy is indicated at this time | null | null | null | null | A | Cefotaxime | Text | STEP 2 | 0.86 | 109.16 | hard | 92 | A | F | A | medium |
259 | A 47-year-old woman comes to the emergency department because of a 2-week history of intermittent abdominal pain, nausea, and vomiting. She has had similar episodes sporadically during the past 4 years. Physical examination shows dehydration, jaundice, and upper abdominal distention. Laboratory studies show hyperbiliru... | Annular pancreas | Cirrhosis of the liver | Duodenal constriction by the portal vein | Duodenal constriction by the superior mesenteric artery | Pyloric stenosis | null | null | null | null | null | A | Annular pancreas | PIX | STEP 1 | 0.9 | 157.46 | hard | 93 | E | D | A | hard |
519 | A 48-year-old man comes to the clinic because of a 10-year history of recurrent, intrusive thoughts that his house will be broken into and damaged by criminals or accidentally destroyed by a fire when he is not home. These thoughts have worsened during the past 2 months. He reports now spending 4 hours daily checking t... | γ-Aminobutyric acid | Dopamine | Glutamate | Norepinephrine | Serotonin | null | null | null | null | null | E | Serotonin | Text | STEP 3 | 0.26 | 50.61 | easy | 94 | E | E | E | easy |
517 | A 58-year-old man comes to the clinic for a follow-up examination 3 months after beginning warfarin therapy for deep venous thrombosis. He noted blood in his urine 1 week ago but has not seen any since that time. He has not had pain, fever, or increased urinary frequency. He has not sustained any recent trauma. His pro... | Adjustment of the warfarin dosage to maintain an INR between 1.5 and 2.0 | Ciprofloxacin therapy | Cystoscopy | Discontinuation of hydrochlorothiazide therapy | Finasteride therapy | null | null | null | null | null | C | Cystoscopy | Text | STEP 2 | 0.2 | 95.09 | easy | 95 | C | C | C | easy |
308 | A 17-year-old girl comes to the physician for an examination prior to entering college. She reports that she feels well but is nervous about leaving home for the first time. She states that she has tried to diet to improve her appearance but that food restriction often "backfires" because she becomes hungry and then en... | Decreased decreased | Decreased increased | Increased decreased | Increased increased | Normal decreased | Normal increased | null | null | null | null | B | Decreased increased | Text | STEP 2 | 0.38 | 78.72 | medium | 96 | D | B | B | medium |
535 | A 67-year-old man is brought to the emergency department by his wife 1 hour after he fainted while getting the morning newspaper. His wife says that he was unconscious for approximately 1 minute; he did not have urinary incontinence or seizure activity during the episode. During the past 2 days, he also has had episode... | Atrial flutter | First-degree atrioventricular block | Mobitz type I atrioventricular block | Mobitz type II (second-degree) atrioventricular block | Sick sinus syndrome | Third-degree atrioventricular block | null | null | null | null | D | Mobitz type II (second-degree) atrioventricular block | PIX | STEP 2 | 0.62 | 121.27 | hard | 97 | E | E | D | hard |
151 | A 6-year-old boy is brought to the emergency department 2 hours after injuring his arm when he fell out of a tree. His mother says that he is extremely active and likes to climb. During the past year, he fractured his right tibia after falling off a trampoline and sustained a concussion after falling off his bicycle.... | Attention-deficit/hyperactivity disorder | Conduct disorder | Learning disorder | Seizure disorder | Age-appropriate behavior | null | null | null | null | null | A | Attention-deficit/hyperactivity disorder | Text | STEP 2 | 0.44 | 81.38 | medium | 98 | A | A | A | easy |
660 | A 25-year-old woman comes to the emergency department because of a 3-hour history of fever, severe headache, light-headedness, dizziness, shaking chills, and muscle aches. Five hours ago, she was diagnosed with Lyme disease and began doxycycline therapy. She has no other history of serious illness and takes no other me... | Exacerbation of infection by Borrelia burgdorferi | Infection-mediated sepsis | IgE-mediated allergic reaction to doxycycline | Release of bacterial products producing acute inflammation | Secretion of bacterial endotoxins | null | null | null | null | null | D | Release of bacterial products producing acute inflammation | Text | STEP 1 | 0.92 | 122.64 | hard | 99 | E | A | E | hard |
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