{"question": "A junior orthopaedic surgery resident is completing a carpal tunnel repair with the department chairman as the attending physician. During the case, the resident inadvertently cuts a flexor tendon. The tendon is repaired without complication. The attending tells the resident that the patient will do fine, and there is no need to report this minor complication that will not harm the patient, as he does not want to make the patient worry unnecessarily. He tells the resident to leave this complication out of the operative report. Which of the following is the correct next action for the resident to take?", "answer": "Tell the attending that he cannot fail to disclose this mistake", "options": {"A": "Disclose the error to the patient and put it in the operative report", "B": "Tell the attending that he cannot fail to disclose this mistake", "C": "Report the physician to the ethics committee", "D": "Refuse to dictate the operative report"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["junior orthopaedic surgery resident", "completing", "carpal tunnel repair", "department chairman", "attending physician", "case", "resident", "cuts", "flexor tendon", "tendon", "repaired", "complication", "attending", "resident", "patient", "fine", "need to report", "minor complication", "not", "patient", "not", "to make", "patient worry", "resident to leave", "complication out", "operative report", "following", "correct next action", "resident to take"]}
{"question": "A 67-year-old man with transitional cell carcinoma of the bladder comes to the physician because of a 2-day history of ringing sensation in his ear. He received this first course of neoadjuvant chemotherapy 1 week ago. Pure tone audiometry shows a sensorineural hearing loss of 45 dB. The expected beneficial effect of the drug that caused this patient's symptoms is most likely due to which of the following actions?", "answer": "Cross-linking of DNA", "options": {"A": "Inhibition of proteasome", "B": "Hyperstabilization of microtubules", "C": "Generation of free radicals", "D": "Cross-linking of DNA"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["67 year old man", "transitional cell carcinoma of the bladder", "physician", "2-day history", "ringing sensation", "ear", "received", "first course", "neoadjuvant chemotherapy 1 week", "Pure tone audiometry shows", "sensorineural hearing loss", "dB", "expected beneficial effect", "drug", "caused", "patient's symptoms", "most likely due to", "following actions"]}
{"question": "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:\nHemoglobin count 14 g/dL\nLeukocyte count 16,400/mm3\nSegmented neutrophils 56%\nEosinophils 11%\nLymphocytes 31%\nMonocytes 2%\nPlatelet count 260,000/mm3\nErythrocyte sedimentation rate 68 mm/h\nSerum\nUrea nitrogen 25 mg/dL\nCreatinine 4.2 mg/dL\nRenal biopsy shows intravascular spindle-shaped vacuoles. Which of the following is the most likely cause of this patient's symptoms?\"", "answer": "Cholesterol embolization", "options": {"A": "Renal papillary necrosis", "B": "Cholesterol embolization", "C": "Eosinophilic granulomatosis with polyangiitis", "D": "Polyarteritis nodosa"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two weeks", "emergency cardiac", "stenting", "unstable angina pectoris", "61 year old man", "decreased urinary output", "malaise", "type 2 diabetes mellitus", "osteoarthritis of", "hips", "admission", "medications", "insulin", "naproxen", "started", "aspirin", "clopidogrel", "metoprolol", "coronary intervention", "temperature", "100 4F", "pulse", "min", "blood pressure", "85 mm Hg", "Examination shows mottled", "reticulated", "discoloration", "feet", "Laboratory studies show", "Hemoglobin count", "Leukocyte 16", "neutrophils", "Platelet count", "Erythrocyte sedimentation rate", "h Serum Urea nitrogen", "mg", "Creatinine", "mg", "Renal biopsy shows intravascular spindle shaped vacuoles", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 39-year-old woman is brought to the emergency department because of fevers, chills, and left lower quadrant pain. Her temperature is 39.1°C (102.3°F), pulse is 126/min, respirations are 28/min, and blood pressure is 80/50 mm Hg. There is blood oozing around the site of a peripheral intravenous line. Pelvic examination shows mucopurulent discharge from the cervical os and left adnexal tenderness. Laboratory studies show:\nPlatelet count 14,200/mm3\nFibrinogen 83 mg/mL (N = 200–430 mg/dL)\nD-dimer 965 ng/mL (N < 500 ng/mL)\nWhen phenol is applied to a sample of the patient's blood at 90°C, a phosphorylated N-acetylglucosamine dimer with 6 fatty acids attached to a polysaccharide side chain is identified. A blood culture is most likely to show which of the following?\"", "answer": "Lactose-fermenting, gram-negative rods forming pink colonies on MacConkey agar", "options": {"A": "Coagulase-positive, gram-positive cocci forming mauve-colored colonies on methicillin-containing agar", "B": "Encapsulated, gram-negative coccobacilli forming grey-colored colonies on charcoal blood agar", "C": "Spore-forming, gram-positive bacilli forming yellow colonies on casein agar", "D": "Lactose-fermenting, gram-negative rods forming pink colonies on MacConkey agar"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "fevers", "chills", "left lower quadrant pain", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "80 50 mm Hg", "blood", "site of", "peripheral line", "Pelvic examination shows mucopurulent discharge", "cervical os", "left adnexal tenderness", "Laboratory studies show", "Platelet count", "200 mm3 Fibrinogen 83 mg/mL", "N", "mg/dL", "D-dimer", "ng/mL", "N", "500 ng/mL", "phenol", "applied", "sample", "patient", "lood ", "cetylglucosamine  imer ", "atty acids  ttached ", "olysaccharide  ide  hain ", "dentified.", "lood culture ", "ost likely  o  how ", "ollowing?"]}
{"question": "A 35-year-old man comes to the physician because of itchy, watery eyes for the past week. He has also been sneezing multiple times a day during this period. He had a similar episode 1 year ago around springtime. He has iron deficiency anemia and ankylosing spondylitis. Current medications include ferrous sulfate, artificial tear drops, and indomethacin. He works as an elementary school teacher. His vital signs are within normal limits. Visual acuity is 20/20 without correction. Physical examination shows bilateral conjunctival injection with watery discharge. The pupils are 3 mm, equal, and reactive to light. Examination of the anterior chamber of the eye is unremarkable. Which of the following is the most appropriate treatment?", "answer": "Ketotifen eye drops", "options": {"A": "Erythromycin ointment", "B": "Ketotifen eye drops", "C": "Warm compresses", "D": "Fluorometholone eye drops"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old man", "physician", "of itchy", "watery", "past week", "sneezing multiple times", "day", "period", "similar episode", "year", "iron deficiency anemia", "ankylosing spondylitis", "Current medications include ferrous sulfate", "artificial tear drops", "indomethacin", "works", "elementary school teacher", "vital signs", "normal limits", "Visual acuity", "20/20", "correction", "Physical examination shows bilateral injection", "watery", "pupils", "3 mm", "equal", "reactive to light", "Examination of the anterior chamber", "eye", "unremarkable", "following", "most appropriate treatment"]}
{"question": "A 39-year-old man presents to the emergency department because of progressively worsening chest pain and nausea that started at a local bar 30 minutes prior. The pain radiates to the epigastric area. He has a 5-year history of untreated hypertension. He has smoked 1 pack of cigarettes daily for the past 5 years and started abusing cocaine 2 weeks before his emergency room visit. The patient is diaphoretic and in marked distress. What should be the first step in management?", "answer": "Reassurance and continuous monitoring", "options": {"A": "Diltiazem", "B": "Labetalol", "C": "Propranolol", "D": "Reassurance and continuous monitoring"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "worsening chest pain", "nausea", "started", "local", "30 minutes prior", "pain radiates", "epigastric area", "5 year history of untreated hypertension", "smoked 1 pack", "cigarettes daily", "past", "years", "started abusing cocaine 2 weeks", "emergency room visit", "patient", "diaphoretic", "marked distress", "first step", "management"]}
{"question": "A 68-year-old male comes to the physician for evaluation of right flank pain. He has a history of diabetes and peripheral artery disease. His blood pressure is 160/90 mm Hg. Physical examination shows abdominal tenderness and right flank tenderness. An ultrasound shows dilation of the right ureter and renal pelvis. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Common iliac artery aneurysm", "options": {"A": "Renal artery stenosis", "B": "Benign prostatic hyperplasia", "C": "Common iliac artery aneurysm", "D": "Urethral stricture"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["68 year old male", "physician", "evaluation", "right flank pain", "history", "diabetes", "peripheral artery disease", "blood pressure", "90 mm Hg", "Physical examination shows abdominal tenderness", "right", "ultrasound shows dilation of", "right ureter", "renal pelvis", "following", "most likely underlying cause", "patient's condition"]}
{"question": "A 65-year-old man is brought to the emergency department 30 minutes after the onset of acute chest pain. He has hypertension and asthma. Current medications include atorvastatin, lisinopril, and an albuterol inhaler. He appears pale and diaphoretic. His pulse is 114/min and blood pressure is 130/88 mm Hg. An ECG shows ST-segment depressions in leads II, III, and aVF. Laboratory studies show an increased serum troponin T concentration. The patient is treated for acute coronary syndrome and undergoes percutaneous transluminal coronary angioplasty. At the time of discharge, echocardiography shows a left ventricular ejection fraction of 58%. In addition to aspirin, which of the following drugs should be added to this patient's medication regimen?", "answer": "Clopidogrel", "options": {"A": "Nifedipine", "B": "Enoxaparin", "C": "Clopidogrel", "D": "Spironolactone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old man", "brought", "emergency department 30 minutes", "onset of acute", "hypertension", "asthma", "Current medications include atorvastatin", "lisinopril", "albuterol inhaler", "appears pale", "diaphoretic", "pulse", "min", "blood pressure", "88 mm Hg", "ECG shows ST-segment depressions", "leads", "III", "aVF", "Laboratory studies show", "increased serum troponin T concentration", "patient", "treated", "acute coronary syndrome", "percutaneous transluminal coronary angioplasty", "time", "discharge", "echocardiography shows", "left ventricular ejection fraction of 58", "aspirin", "following drugs", "added", "patient's medication regimen"]}
{"question": "A 37-year-old-woman presents to her primary care physician requesting a new form of birth control. She has been utilizing oral contraceptive pills (OCPs) for the past 8 years, but asks to switch to an intrauterine device (IUD). Her vital signs are: blood pressure 118/78 mm Hg, pulse 73/min and respiratory rate 16/min. She is afebrile. Physical examination is within normal limits. Which of the following past medical history statements would make copper IUD placement contraindicated in this patient?", "answer": "Active or recurrent pelvic inflammatory disease (PID)", "options": {"A": "A history of stroke or venous thromboembolism", "B": "Active or recurrent pelvic inflammatory disease (PID)", "C": "Past medical history of breast cancer", "D": "Known liver neoplasm"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician requesting", "new form", "birth control", "oral contraceptive pills", "past", "years", "to switch", "intrauterine device", "vital signs", "blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "min", "afebrile", "Physical examination", "normal limits", "of", "following past medical statements", "make copper IUD placement contraindicated", "patient"]}
{"question": "A 23-year-old woman comes to the physician because she is embarrassed about the appearance of her nails. She has no history of serious illness and takes no medications. She appears well. A photograph of the nails is shown. Which of the following additional findings is most likely in this patient?", "answer": "Silvery plaques on extensor surfaces", "options": {"A": "Silvery plaques on extensor surfaces", "B": "Flesh-colored papules in the lumbosacral region", "C": "Erosions of the dental enamel", "D": "Holosystolic murmur at the left lower sternal border"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old woman", "physician", "embarrassed", "appearance of", "nails", "history", "serious illness", "takes", "medications", "appears well", "photograph", "nails", "shown", "following additional findings", "most likely", "patient"]}
{"question": "A 24-year-old G2P1 woman at 39 weeks’ gestation presents to the emergency department complaining of painful contractions occurring every 10 minutes for the past 2 hours, consistent with latent labor. She says she has not experienced vaginal discharge, bleeding, or fluid leakage, and is currently taking no medications. On physical examination, her blood pressure is 110/70 mm Hg, heart rate is 86/min, and temperature is 37.6°C (99.7°F). She has had little prenatal care and uses condoms inconsistently. Her sexually transmitted infections status is unknown. As part of the patient’s workup, she undergoes a series of rapid screening tests that result in the administration of zidovudine during delivery. The infant is also given zidovudine to reduce the risk of transmission. A confirmatory test is then performed in the mother to confirm the diagnosis of HIV. Which of the following is most true about the confirmatory test?", "answer": "It is an HIV-1/HIV2 antibody differentiation immunoassay", "options": {"A": "It is a Southwestern blot, identifying the presence of DNA-binding proteins", "B": "It is a Northern blot, identifying the presence of RNA", "C": "It is a Northern blot, identifying the presence of DNA", "D": "It is an HIV-1/HIV2 antibody differentiation immunoassay"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old", "woman", "weeks presents", "emergency department", "painful contractions occurring", "10", "past", "hours", "consistent with latent labor", "not experienced vaginal discharge", "bleeding", "fluid leakage", "currently taking", "medications", "physical examination", "blood pressure", "70 mm Hg", "heart rate", "min", "temperature", "99", "little prenatal care", "uses condoms", "sexually transmitted infections status", "unknown", "part of", "patients workup", "series", "rapid screening tests", "result", "administration", "zidovudine", "delivery", "infant", "zidovudine to", "risk", "transmission", "confirmatory test", "then performed", "mother to confirm", "diagnosis", "HIV", "following", "most true", "confirmatory test"]}
{"question": "A 72-year-old man comes to the physician because of a 2-month history of fatigue and worsening abdominal pain. During this period, he also has excessive night sweats and shortness of breath on exertion. Over the past 3 months, he has had a 5.6-kg (12-lb) weight loss. He had a myocardial infarction 3 years ago. He has hypertension, diabetes mellitus, and chronic bronchitis. His medications include insulin, aspirin, lisinopril, and an albuterol inhaler. He has smoked half a pack of cigarettes for the past 45 years. Vital signs are within normal limits. The spleen is palpated 6 cm below the left costal margin. Laboratory studies show:\nHemoglobin 6.4 g/dL\nMean corpuscular volume 85 μm3\nLeukocyte count 5,200/mm3\nPlatelet count 96,000/mm3\nA blood smear is shown. Bone marrow aspiration shows extensive fibrosis and a few scattered plasma cells. A JAK 2 assay is positive. Which of the following is the most appropriate next step in management?\"", "answer": "Ruxolitinib", "options": {"A": "Cladribine", "B": "Prednisone", "C": "Imatinib", "D": "Ruxolitinib"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["72 year old man", "physician", "2 month history", "fatigue", "worsening abdominal pain", "period", "excessive night sweats", "shortness of breath", "exertion", "past 3 months", "5.6 kg", "weight loss", "myocardial infarction", "years", "hypertension", "diabetes mellitus", "chronic bronchitis", "medications include insulin", "aspirin", "lisinopril", "albuterol inhaler", "smoked half", "pack", "cigarettes", "past", "years", "Vital signs", "normal limits", "spleen", "palpated", "cm", "left costal margin", "Laboratory studies show", "Hemoglobin", "g Mean corpuscular volume 85 m3 Leukocyte count", "200 mm3 Platelet count 96", "blood smear", "shown", "Bone marrow aspiration shows extensive fibrosis", "few scattered plasma cells", "JAK 2 assay", "positive", "following", "most appropriate next step", "management"]}
{"question": "A 20-year-old man comes to the physician because of worsening gait unsteadiness and bilateral hearing loss for 1 month. He has had intermittent tingling sensations on both cheeks over this time period. He has no history of serious medical illness and takes no medications. Audiometry shows bilateral sensorineural hearing loss. Genetic evaluation shows a mutation of a tumor suppressor gene on chromosome 22 that encodes merlin. This patient is at increased risk for which of the following conditions?", "answer": "Meningioma", "options": {"A": "Renal cell carcinoma", "B": "Meningioma", "C": "Astrocytoma", "D": "Vascular malformations"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["20 year old man", "physician", "worsening gait unsteadiness", "bilateral hearing loss", "month", "intermittent tingling sensations", "cheeks", "time period", "history of serious medical illness", "takes", "medications", "Audiometry shows bilateral sensorineural hearing loss", "Genetic evaluation shows", "mutation", "tumor suppressor gene", "chromosome 22", "encodes merlin", "patient", "increased risk", "following conditions"]}
{"question": "A 47-year-old executive schedules an appointment his physician for a routine medical check-up. He currently has no complaints and claims to be “as fit as a fiddle.” The physical examination findings are unremarkable, except for a mid-systolic murmur heard in the 2nd left intercostal space that radiates to the carotids on auscultation. The physician instructs the patient to stand from a supine position with the stethoscope still placed on his chest. Which of the following changes would occur with this maneuver?", "answer": "A reduction in diastolic filling time", "options": {"A": "An increase in right atrial pressure", "B": "An increase in pulmonary capillary wedge pressure", "C": "A reduction in the slope of the pacemaker potential", "D": "A reduction in diastolic filling time"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old executive schedules", "appointment", "physician", "routine medical check-up", "currently", "complaints", "to", "fit", "physical examination findings", "unremarkable", "except for", "systolic murmur heard", "2nd left intercostal space", "radiates", "carotids", "auscultation", "physician", "patient to stand", "supine position", "stethoscope", "placed", "chest", "following changes", "occur"]}
{"question": "A microbiologist is studying the emergence of a virulent strain of the virus. After a detailed study of the virus and its life cycle, he proposes a theory: Initially, a host cell is co-infected with 2 viruses from the same virus family. Within the host cell, concomitant production of various genome segments from both viruses occurs. Ultimately, the different genome segments from the viruses are packaged into a unique and novel virus particle. The newly formed virus particle is both stable and viable and is a new strain from the virus family that caused the outbreak of infection. Which of the following viruses is capable of undergoing the above-mentioned process?", "answer": "Rotavirus", "options": {"A": "Epstein-Barr virus", "B": "Human immunodeficiency virus", "C": "Rotavirus", "D": "Vaccinia virus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["microbiologist", "studying", "emergence", "virulent strain", "virus", "detailed study", "virus", "life cycle", "theory", "Initially", "host cell", "co infected", "viruses", "same virus family", "host cell", "concomitant production", "various genome segments", "viruses occurs", "different genome segments", "viruses", "packaged", "unique", "novel virus particle", "newly formed virus particle", "stable", "viable", "new strain", "virus family", "caused", "outbreak", "infection", "following viruses", "capable", "process"]}
{"question": "A 59-year-old overweight woman presents to the urgent care clinic with the complaint of severe abdominal pain for the past 2 hours. She also complains of a dull pain in her back with nausea and vomiting several times. Her pain has no relation with food. Her past medical history is significant for recurrent abdominal pain due to cholelithiasis. Her father died at the age of 60 with some form of abdominal cancer. Her temperature is 37°C (98.6°F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Physical exam is unremarkable. However, a CT scan of the abdomen shows a calcified mass near her gallbladder. Which of the following diagnoses should be excluded first in this patient?", "answer": "Gallbladder cancer", "options": {"A": "Acute cholecystitis", "B": "Gallbladder cancer", "C": "Choledocholithiasis", "D": "Pancreatitis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old overweight woman presents", "urgent care clinic", "complaint", "severe abdominal", "past", "hours", "dull pain", "back", "nausea", "vomiting", "times", "pain", "relation", "food", "past medical history", "significant", "recurrent abdominal pain", "cholelithiasis", "father died", "age", "60", "form", "abdominal cancer", "temperature", "98", "respirations", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "Physical exam", "unremarkable", "CT scan", "abdomen shows", "calcified mass", "gallbladder", "following diagnoses", "excluded first", "patient"]}
{"question": "A 7-year-old boy is brought to his pediatrician’s office for a follow-up visit. He was diagnosed with asthma when he was 3 years old and has since been on treatment for the condition. He is currently on a β-agonist inhaler because of exacerbation of his symptoms. He has observed that his symptoms are more prominent in springtime, especially when the new flowers are blooming. His mother has a backyard garden and whenever he goes out to play there, he experiences chest tightness with associated shortness of breath. He has been advised to take more precaution during this seasonal change and to stay away from pollen. He is also being considered for an experimental therapy, which attenuates the activity of certain mediators which cause his asthmatic attack. The targeted mediator favors the class switching of antibodies. A reduction in this mechanism will eventually reduce the exaggerated response observed during his asthmatic attacks, even when exposed to an allergen. Which of the following mediators is described in this experimental study?", "answer": "IL-4", "options": {"A": "IL-2", "B": "IL-10", "C": "IL-13", "D": "IL-4"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "pediatricians office", "follow-up visit", "diagnosed", "asthma", "3 years old", "since", "on treatment", "condition", "currently", "agonist inhaler", "exacerbation", "symptoms", "observed", "symptoms", "more prominent", "new flowers", "mother", "backyard garden", "goes out to play", "experiences chest tightness with associated shortness of breath", "to take more precaution", "seasonal change", "to", "pollen", "considered", "experimental therapy", "attenuates", "activity", "certain mediators", "cause", "asthmatic attack", "targeted mediator favors", "class switching", "antibodies", "reduction", "mechanism", "exaggerated response observed", "asthmatic attacks", "exposed", "allergen", "following mediators", "described", "experimental study"]}
{"question": "A 3-month-old boy is brought the emergency department by his parents after an episode of cyanosis and muscle hypotonia that resolved after 2 minutes. Diagnostic evaluation fails to discover an exact etiology of the boy's symptoms and the episode is classified as a brief resolved unexplained event (BRUE). The risk profile for BRUE in infants remains largely unknown. The pediatrician who saw the boy in the emergency department is trying to identify risk factors for BRUE. She is aware of several confounders, including age, socioeconomic background, and family history of medical illness. She recruits 75 infants under 1 year of age with BRUE and 75 infants without BRUE of the same age, socioeconomic background, and family history of medical illness. She then compares the two groups with regard to history of feeding problems and history of recent upper respiratory infection. Which of the following methods was conducted to control confounding bias in the study?", "answer": "Matching", "options": {"A": "Blinding", "B": "Restriction", "C": "Randomization", "D": "Matching"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 month old boy", "brought", "emergency department", "parents", "episode of cyanosis", "muscle hypotonia", "resolved", "minutes", "Diagnostic evaluation fails to discover", "exact etiology", "boy's symptoms", "episode", "classified", "brief resolved unexplained event", "risk profile", "BRUE", "infants", "unknown", "pediatrician", "saw", "boy", "emergency department", "to", "risk factors", "BRUE", "aware", "including age", "socioeconomic background", "family history of medical illness", "75 infants", "year", "age", "BRUE", "75 infants", "BRUE", "same age", "socioeconomic background", "family history of medical illness", "then compares", "two groups", "history", "feeding problems", "history", "recent upper respiratory infection", "following methods", "conducted to control", "bias", "study"]}
{"question": "A 29-year-old man presents to the emergency department due to central chest pain over the past 3 days which is constant and unrelated to exertion. The pain is sharp, severe, increases when lying down, and improves with leaning forward. The pain also radiates to his shoulders and neck. The patient has no past medical history. He has smoked 10 cigarettes per day for the past 7 years and occasionally drinks alcohol. He presents with vital signs: blood pressure 110/70 mm Hg, regular radial pulse of 95/min, and temperature 37.3°C (99.1°F). On physical exam, a scratching sound of to-and-from character is audible over the left sternal border at end-expiration with the patient leaning forward. His chest X-ray is normal and ECG is shown in the picture. Which of the following is the optimal therapy for this patient?", "answer": "Ibuprofen + colchicine +/- omeprazole", "options": {"A": "Indomethacin +/- omeprazole", "B": "Ibuprofen + colchicine +/- omeprazole", "C": "Pericardiocentesis", "D": "Pericardiectomy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old man presents", "emergency department due to central chest pain", "past 3 days", "constant", "unrelated", "exertion", "pain", "sharp", "severe", "increases", "lying", "improves", "forward", "pain", "radiates", "shoulders", "neck", "patient", "past medical history", "smoked 10 cigarettes", "day", "past", "years", "occasionally drinks alcohol", "presents", "vital signs", "blood pressure", "70 mm Hg", "regular radial pulse", "95 min", "temperature", "3C", "99", "physical exam", "scratching sound", "character", "left sternal border", "end-expiration", "patient", "forward", "chest X-ray", "normal", "ECG", "shown", "picture", "following", "optimal therapy", "patient"]}
{"question": "A 46-year-old man is brought to the emergency department for evaluation of altered mental status. He was found on the floor in front of his apartment. He is somnolent but responsive when aroused. His pulse is 64/min, respiratory rate is 15/min, and blood pressure is 120/75 mm Hg. On physical examination, an alcoholic smell and slurred speech are noted. Neurological exam shows diminished deep tendon reflexes bilaterally and an ataxic gait. His pupils are normal. Blood alcohol concentration is 0.04%. An ECG shows no abnormalities. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Benzodiazepine intoxication\n\"", "options": {"A": "Hypoglycemia", "B": "Ethanol intoxication", "C": "Cannabis intoxication", "D": "Benzodiazepine intoxication\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "evaluation of altered mental status", "found on", "floor", "apartment", "somnolent", "responsive", "aroused", "pulse", "64 min", "respiratory rate", "min", "blood pressure", "75 mm Hg", "physical examination", "alcoholic smell", "slurred speech", "noted", "Neurological exam shows diminished deep tendon reflexes", "ataxic gait", "pupils", "normal", "Blood alcohol concentration", "0.04", "ECG shows", "abnormalities", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 77-year-old woman presents to the emergency room with the complaints of fever, malaise, and night sweats. She recently observed an enlargement of her axillary lymph nodes, which she examines on a weekly basis. She has a remote history of breast cancer in her 60s that was treated with radiation and chemotherapy. She also reports a history of extensive travel to Africa and a 30-pack-year history of smoking. On physical exam, several axillary lymph nodes are palpable with a large non-tender palpable mass in her right axilla measuring 10 x 8 cm. Fine-needle aspiration demonstrates what the pathologist describes as \"a centroblastic and immunoblastic cell presence, suspicious for non-Hodgkin’s lymphoma (NHL)–diffuse large B cell variant\". Which of the following risk factors is responsible for this patient’s condition?", "answer": "Previous radiation therapy", "options": {"A": "Travel to Africa", "B": "Axillary lymph node involvement", "C": "Previous radiation therapy", "D": "Previous breast cancer"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency room", "complaints", "fever", "malaise", "night sweats", "recently observed", "enlargement of", "axillary lymph nodes", "weekly basis", "remote history of breast cancer", "treated with radiation", "chemotherapy", "reports", "history of extensive travel", "Africa", "30 pack-year history of smoking", "physical exam", "several axillary lymph nodes", "palpable", "large non-tender", "mass", "right axilla measuring 10", "8", "Fine-needle aspiration demonstrates", "pathologist", "immunoblastic cell presence", "suspicious", "non-Hodgkins lymphoma", "diffuse large B cell variant", "following risk factors", "responsible", "patients condition"]}
{"question": "A 3-month-old infant is brought to her pediatrician because she coughs and seems to have difficulty breathing while feeding. In addition, she seems to have less energy compared to other babies and appears listless throughout the day. She was born by cesarean section to a G1P1 woman with no prior medical history and had a normal APGAR score at birth. Her parents say that she has never been observed to turn blue. Physical exam reveals a high-pitched holosystolic murmur that is best heard at the lower left sternal border. The most likely cause of this patient's symptoms is associated with which of the following abnormalities?", "answer": "22q11 deletion", "options": {"A": "22q11 deletion", "B": "Deletion of genes on chromosome 7", "C": "Lithium exposure in utero", "D": "Maternal alcohol consumption"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 month old infant", "brought", "pediatrician", "coughs", "to", "difficulty breathing", "feeding", "addition", "to", "less energy compared", "babies", "appears listless", "day", "born by cesarean section to", "G1P1 woman", "prior medical history", "normal APGAR score at birth", "parents", "never", "observed to turn blue", "Physical exam reveals", "high-pitched holosystolic murmur", "best heard", "lower left sternal border", "most likely cause", "patient's symptoms", "associated with", "following abnormalities"]}
{"question": "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?", "answer": "Histoplasma capsulatum infection", "options": {"A": "Legionella pneumophila infection", "B": "Pneumocystis pneumonia", "C": "Histoplasma capsulatum infection", "D": "Blastomyces dermatitidis infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old African American woman", "physician", "evaluation", "dry cough", "chest discomfort", "past 3 days", "period", "patient", "headaches", "muscle aches", "joint pain", "fever", "chills", "Ten days", "hiking", "family", "Mississippi", "patient", "asthma", "treated with", "albuterol inhaler", "mother", "lung disease treated with methotrexate", "patient", "smoked one pack", "cigarettes daily", "past 10 years", "temperature", "100 4F", "Physical examination shows slight wheezes", "lung fields", "Laboratory studies", "urinalysis", "positive", "polysaccharide antigen", "Bronchoalveolar lavage using silver PAS staining shows macrophages filled", "dimorphic fungus", "septate hyphae", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 62-year-old patient has been hospitalized for a week due to a stroke. One week into the hospitalization, he develops a fever and purulent cough. His vitals include: heart rate 88/min, respiratory rate 20/min, temperature 38.4°C (101.1°F), and blood pressure 110/85 mm Hg. On physical examination, he has basal crackles on the right side of the chest. Chest radiography shows a new consolidation on the same side. Complete blood count is as follows:\nHemoglobin 16 mg/dL\nHematocrit 50%\nLeukocyte count 8,900/mm3\nNeutrophils 72%\nBands 4%\nEosinophils 2%\nBasophils 0%\nLymphocytes 17%\nMonocytes 5%\nPlatelet count 280,000/mm3\nWhat is the most likely causal microorganism?", "answer": "Staphylococcus aureus", "options": {"A": "Streptococcus pneumoniae", "B": "Mycobacterium tuberculosis", "C": "Haemophilus influenzae", "D": "Staphylococcus aureus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old patient", "hospitalized", "week", "stroke", "One week", "hospitalization", "fever", "purulent cough", "include", "heart rate 88 min", "respiratory rate 20 min", "temperature", "4C", "blood pressure", "85 mm Hg", "physical examination", "basal crackles", "right side of", "chest", "Chest radiography shows", "new consolidation", "same side", "Complete blood count", "follows", "Hemoglobin", "Hematocrit 50", "Leukocyte count 8 900 mm3", "72", "Bands 4", "Eosinophils 2", "Basophils 0", "Lymphocytes", "Monocytes 5", "Platelet count", "most likely causal microorganism"]}
{"question": "A 6-year-old boy is brought to the emergency department by his mother for worsening wheezing and shortness of breath over the past day. He has not had a fever, cough, vomiting, or diarrhea. He has asthma and eczema. He uses a glucocorticoid inhaler and an albuterol inhaler but has missed his medications for the past week while on vacation. He appears uncomfortable. His temperature is 36°C (96.8°F), pulse is 120/min, respirations are 40/min, and blood pressure is 100/80. Expiratory and inspiratory wheezing is heard throughout both lung fields. There are moderate intercostal and subcostal retractions and a decreased inspiratory to expiratory ratio. Nebulized albuterol and ipratropium treatments and intravenous methylprednisolone are given in the emergency department for a presumed asthma exacerbation. One hour later, the child is limp and lethargic. Magnesium sulfate is administered. His temperature is 36°C (96.8°F), pulse is 150/min, respirations are 22/min, and blood pressure is 100/70. No wheezing is heard on repeat pulmonary examination. Which of the following is the most appropriate next step in management?", "answer": "Intubate with mechanical ventilation", "options": {"A": "Intubate with mechanical ventilation", "B": "Perform needle thoracostomy at the 2nd intercostal space", "C": "Perform bronchoscopy", "D": "Provide additional dose of methylprednisolone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "mother", "worsening wheezing", "shortness of breath", "past day", "not", "fever", "cough", "vomiting", "diarrhea", "asthma", "eczema", "uses", "glucocorticoid inhaler", "albuterol inhaler", "missed", "medications", "past week", "vacation", "appears", "temperature", "96", "pulse", "min", "respirations", "40 min", "blood pressure", "100 80", "Expiratory", "inspiratory wheezing", "heard", "lung fields", "moderate", "subcostal retractions", "decreased inspiratory", "expiratory ratio", "Nebulized albuterol", "ipratropium treatments", "intravenous methylprednisolone", "given", "emergency department", "presumed asthma exacerbation", "One hour later", "child", "limp", "lethargic", "Magnesium sulfate", "administered", "temperature", "96", "pulse", "min", "respirations", "min", "blood pressure", "100 70", "wheezing", "heard", "repeat pulmonary examination", "following", "most appropriate next step", "management"]}
{"question": "A 5-year-old female suffers from recurrent infections by Aspergillus species, Pseudomonas species, and Staphylococcus aureus. The patient's neutrophils are examined in the laboratory and they fail to react during the nitroblue tetrazolium test. Which of the following is most likely dysfunctional in this patient?", "answer": "Respiratory burst", "options": {"A": "Immunoglobulin class switching", "B": "Superoxide dismutase", "C": "Myeloperoxidase", "D": "Respiratory burst"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old female suffers", "recurrent infections", "Aspergillus species", "Pseudomonas species", "Staphylococcus aureus", "patient's neutrophils", "examined", "laboratory", "fail to react", "nitroblue tetrazolium test", "following", "most likely dysfunctional", "patient"]}
{"question": "A 3-year-old boy presents to the emergency department with a ‘cough-like-a-seal bark’ and a high-pitched inspiratory noise that is audible without a stethoscope. His mother reports that his cough has worsened over the last few hours. The patient's blood pressure is 118/78 mm Hg, pulse is 90/min, respiratory rate is 35/min, and temperature is 38.3°C (101.1°F). On physical examination, the boy is sitting and leaning forward in apparent respiratory distress with suprasternal and intercostal retractions. Auscultation reveals inspiratory stridor without wheezing. He has a frequent barking cough and a hoarse voice when he speaks. What is a chest X-ray likely to show?", "answer": "Steeple sign", "options": {"A": "Increased interstitial markings", "B": "Lobar consolidation in the lingual", "C": "Thumbprint sign on the lateral image", "D": "Steeple sign"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 year old boy presents", "emergency department", "cough", "seal bark", "high-pitched inspiratory noise", "stethoscope", "mother reports", "cough", "worsened", "hours", "patient's blood pressure", "mm Hg", "pulse", "90 min", "respiratory rate", "35 min", "temperature", "3C", "physical examination", "boy", "sitting", "forward", "apparent respiratory distress", "suprasternal", "intercostal retractions", "Auscultation reveals inspiratory", "wheezing", "frequent barking cough", "hoarse voice", "speaks", "chest X-ray likely to show"]}
{"question": "A 26-year-old woman presents to a gynecologist after a missed period. After performing a complete physical examination and a screening test for pregnancy, her gynecologist informs her that she is pregnant. She is very surprised as she has been taking oral contraceptives regularly. When the gynecologist asks her about the consumption of any other medications, she mentions that she was placed on treatment for pulmonary tuberculosis (TB) 2 months ago. Her current anti-TB regimen includes rifampin, isoniazid, pyrazinamide, and ethambutol. Which of the following mechanisms best explains the failure of oral contraceptives in this patient?", "answer": "Induction of CYP3A4 by rifampin leading to decreased serum levels of ethinylestradiol and progesterone", "options": {"A": "Induction of CYP3A4 by rifampin leading to decreased serum levels of ethinylestradiol and progesterone", "B": "Induction of CYP2A6 by rifampin leading to increased inactivation of ethinylestradiol", "C": "Interference with the intestinal absorption of the oral contraceptive by pyrazinamide", "D": "Increased renal elimination of the progesterone component of the oral contraceptive by ethambutol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "gynecologist", "missed period", "performing", "complete physical examination", "screening", "pregnancy", "gynecologist informs", "pregnant", "very", "taking oral contraceptives", "gynecologist", "consumption", "medications", "placed on treatment", "pulmonary tuberculosis", "months", "current", "TB regimen includes rifampin", "isoniazid", "pyrazinamide", "ethambutol", "following mechanisms best", "failure", "oral contraceptives", "patient"]}
{"question": "A 4-year-old previously healthy boy presents with 4 days of intermittent vomiting and 5-6 daily loose stools. His mother noted bloody stools and decreased oral intake of food and water over the last 24 hours. He is normally in daycare; however, he has been home for the past 3 days. On physical exam his temperature is 102.2°F (39°C), blood pressure is 140/90 mmHg, pulse is 120/min, respirations are 22/min and O2 saturation is 99% on room air. He has dry mucous membranes. On abdominal exam you note diffuse tenderness to palpation without rebound or guarding. There are no masses, hepatosplenomegaly, and bowel sounds are hyperactive. Ultrasound of the right lower quadrant is negative for appendicitis. Stool is guaiac positive. He receives 15mg/kg acetaminophen and fluids are started. The next day, he complains of lower extremity weakness and tingling. On repeat exam, lower extremity strength is 3/5 with diminished patellar deep tendon reflexes. Which of the following lab findings would most likely be seen in this patient?", "answer": "Increased cerebrospinal fluid protein with normal cell count", "options": {"A": "Gram stain positive CSF", "B": "Peripheral eosinophilia", "C": "Xanthochromia on cerebrospinal fluid analysis", "D": "Increased cerebrospinal fluid protein with normal cell count"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old", "healthy boy presents", "4 days", "intermittent vomiting", "5-6 daily loose stools", "mother noted bloody stools", "decreased oral intake", "food", "water", "24 hours", "daycare", "home", "past 3 days", "physical exam", "temperature", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "O2 saturation", "99", "room air", "dry mucous membranes", "abdominal exam", "note diffuse tenderness", "palpation", "guarding", "masses", "hepatosplenomegaly", "bowel sounds", "hyperactive", "Ultrasound", "right lower quadrant", "negative", "appendicitis", "Stool", "guaiac positive", "receives", "kg acetaminophen", "fluids", "started", "next day", "lower extremity weakness", "tingling", "repeat exam", "lower extremity strength", "3/5", "diminished patellar deep tendon reflexes", "following lab findings", "most likely", "seen", "patient"]}
{"question": "A 3-week-old male newborn is brought to the physician because of an inward turning of his left forefoot. He was born at 38 weeks' gestation by cesarean section because of breech presentation. The pregnancy was complicated by oligohydramnios. Examination shows concavity of the medial border of the left foot with a skin crease just below the ball of the great toe. The lateral border of the left foot is convex. The heel is in neutral position. Tickling the lateral border of the foot leads to correction of the deformity. The remainder of the examination shows no abnormalities. X-ray of the left foot shows an increased angle between the 1st and 2nd metatarsal bones. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Reassurance", "options": {"A": "Foot abduction brace", "B": "Arthrodesis of the forefoot", "C": "Reassurance", "D": "Tarsometatarsal capsulotomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["3 week old male newborn", "brought", "physician", "inward turning", "left forefoot", "born", "weeks", "gestation", "cesarean section", "breech presentation", "pregnancy", "complicated", "oligohydramnios", "Examination shows concavity of", "medial border", "left foot", "skin crease", "ball", "great toe", "lateral border of", "left foot", "convex", "heel", "neutral position", "Tickling", "lateral border of", "foot leads", "correction", "deformity", "examination shows", "abnormalities", "X-ray of", "left foot shows", "increased angle", "1st", "2nd metatarsal bones", "following", "most appropriate next step", "management", "patient"]}
{"question": "A 42-year-old woman comes to the emergency department because of a 2-day history of right upper abdominal pain and nausea. She is 163 cm (5 ft 4 in) tall and weighs 91 kg (200 lb); her BMI is 34 kg/m2. Her temperature is 38.5°C (101.3°F). Physical examination shows a distended abdomen and right upper quadrant tenderness with normal bowel sounds. Laboratory studies show:\nLeukocyte count 14,000/mm3\nSerum\nTotal bilirubin 1.1 mg/dL\nAST 32 U/L\nALT 40 U/L\nAlkaline phosphatase 68 U/L\nAbdominal ultrasonography is performed, but the results are inconclusive. Cholescintigraphy shows the intrahepatic bile ducts, hepatic ducts, common bile duct, and proximal small bowel. Which of the following is the most likely cause of this patient's symptoms?\"", "answer": "Obstruction of the cystic duct", "options": {"A": "Autodigestion of pancreatic parenchyma", "B": "Fistula between the gallbladder and small intestine", "C": "Infection with a hepatotropic virus", "D": "Obstruction of the cystic duct"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "emergency department", "2-day history", "right upper", "nausea", "5 ft 4", "tall", "kg", "200", "BMI", "kg/m2", "temperature", "Physical examination shows", "distended abdomen", "right upper quadrant tenderness", "normal bowel sounds", "Laboratory studies show", "Leukocyte", "Serum Total bilirubin", "mg", "L", "Alkaline phosphatase", "Abdominal ultrasonography", "performed", "results", "inconclusive", "shows", "intrahepatic bile ducts", "hepatic ducts", "common bile duct", "proximal small bowel", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 72-year-old woman is admitted to the intensive care unit for shortness of breath and palpitations. A cardiac catheterization is performed and measurements of the left ventricular volume and pressure at different points in the cardiac cycle are obtained. The patient's pressure-volume loop (gray) is shown with a normal pressure-volume loop (black) for comparison. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Increased ventricular wall stiffness", "options": {"A": "Mitral valve regurgitation", "B": "Increased systemic vascular resistance", "C": "Increased ventricular wall stiffness", "D": "Impaired left ventricular contractility"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old woman", "admitted to", "intensive care unit", "shortness of breath", "palpitations", "cardiac catheterization", "performed", "measurements", "left ventricular volume", "pressure", "different points", "cardiac cycle", "obtained", "patient's pressure-volume loop", "gray", "shown", "normal pressure-volume loop", "black", "comparison", "following", "most likely underlying cause", "patient's symptoms"]}
{"question": "A 22-year-old woman is brought to the emergency department because of a 2-day history of fever, intermittent rigors, and night sweats. She also has a 1-month history of progressive fatigue. Five weeks ago, she was hospitalized and received intravenous antibiotics for treatment of bacterial meningitis while visiting relatives in Guatemala. Her temperature is 39.4°C (102.9°F), pulse is 130/min, and blood pressure is 105/70 mm Hg. Examination shows pallor and scattered petechiae and ecchymoses. Laboratory studies show a hemoglobin concentration of 9.0 g/dL, a leukocyte count of 1,100/mm3 with 30% segmented neutrophils, and a platelet count of 20,000/mm3 . Blood cultures grow coagulase-negative staphylococci. The patient was most likely treated with which of the following antibiotics?", "answer": "Chloramphenicol", "options": {"A": "Doxycycline", "B": "Trimethoprim/sulfamethoxazole", "C": "Linezolid", "D": "Chloramphenicol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "2-day history", "fever", "intermittent rigors", "night sweats", "1 month history", "progressive fatigue", "Five weeks", "hospitalized", "received intravenous antibiotics", "treatment", "bacterial meningitis", "visiting relatives", "Guatemala", "temperature", "4C", "9F", "pulse", "min", "blood pressure", "70 mm Hg", "Examination shows pallor", "scattered petechiae", "ecchymoses", "Laboratory studies show a hemoglobin concentration", "9.0 g/dL", "leukocyte count", "1 100 mm3", "30", "segmented neutrophils", "platelet count of 20", "mm3", "Blood cultures", "coagulase-negative staphylococci", "patient", "most likely treated with", "following antibiotics"]}
{"question": "An otherwise healthy 50-year-old man comes to the physician because of a 6-month history of increasingly frequent episodes of upper abdominal pain, nausea, vomiting, and diarrhea. He has had a 3.2-kg (7-lb) weight loss during this time. Physical examination shows bilateral pitting pedal edema. An endoscopy shows prominent rugae in the gastric fundus. Biopsy shows parietal cell atrophy. Which of the following is the most likely underlying cause?", "answer": "Proliferation of gastric mucus-producing cells", "options": {"A": "Serotonin-secreting gastric tumor", "B": "Proliferation of gastric mucus-producing cells", "C": "Excessive somatostatin secretion", "D": "Ectopic secretion of gastrin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 50 year old man", "physician", "of", "month history", "frequent episodes", "upper abdominal pain", "nausea", "vomiting", "diarrhea", "3.2 kg", "weight loss", "time", "Physical examination shows bilateral pitting pedal edema", "endoscopy shows prominent rugae", "gastric", "Biopsy shows parietal cell atrophy", "following", "most likely underlying cause"]}
{"question": "A 27-year-old man presents to the emergency department. He was brought in by staff from the homeless shelter when they found him unresponsive. The patient is a known IV drug abuser but otherwise has an unknown past medical history. He currently attends a methadone clinic. His temperature is 99.5°F (37.5°C), blood pressure is 97/48 mmHg, pulse is 140/min, respirations are 29/min, and oxygen saturation is 98% on room air. Initial laboratory values are shown below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 6.3 mEq/L\nHCO3-: 17 mEq/L\nGlucose: 589 mg/dL\n\nThe patient is given treatment. After treatment, his temperature is 99.5°F (37.5°C), blood pressure is 117/78 mmHg, pulse is 100/min, respirations are 23/min, and oxygen saturation is 98% on room air. His laboratory values are seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 19 mEq/L\nGlucose: 90 mg/dL\n\nWhich of the following is the best next step in management?", "answer": "Insulin, potassium, IV fluids, and glucose", "options": {"A": "Insulin, potassium, IV fluids, and glucose", "B": "IV fluids only", "C": "Oral rehydration", "D": "Supportive therapy and close monitoring"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "emergency department", "brought", "staff", "homeless shelter", "found", "unresponsive", "patient", "known IV drug abuser", "unknown past medical history", "currently attends", "methadone clinic", "temperature", "99", "blood pressure", "97 48 mmHg", "pulse", "min", "respirations", "29 min", "oxygen saturation", "98", "room air", "Initial laboratory values", "shown", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "6.3 mEq/L HCO3", "mEq/L Glucose", "mg/dL", "patient", "given treatment", "treatment", "temperature", "99", "blood pressure", "mmHg", "pulse", "100 min", "respirations", "23 min", "oxygen saturation", "98", "room air", "laboratory values", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L Glucose", "90 mg/dL", "following", "best next step", "management"]}
{"question": "A 67-year-old man who was diagnosed with arthritis 16 years ago presents with right knee swelling and pain. His left knee was swollen a few weeks ago, but now with both joints affected, he has difficulty walking and feels frustrated. He also has back pain which makes it extremely difficult to move around and be active during the day. He says his pain significantly improves with rest. He also suffers from dandruff for which he uses special shampoos. Physical examination is notable for pitting of his nails. Which of the following is the most likely diagnosis?", "answer": "Psoriatic arthritis", "options": {"A": "Psoriatic arthritis", "B": "Arthritis mutilans", "C": "Rheumatoid arthritis", "D": "Mixed connective tissue disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man", "diagnosed", "arthritis", "years", "presents", "right", "pain", "left knee", "swollen", "few weeks", "now", "joints affected", "difficulty walking", "feels frustrated", "back pain", "makes", "extremely difficult to move", "active", "day", "pain", "improves", "rest", "suffers", "dandruff", "uses special shampoos", "Physical examination", "notable", "pitting of", "nails", "following", "most likely diagnosis"]}
{"question": "A 65-year-old woman schedules an appointment with her physician for evaluation of weight loss and weakness. The weakness is more noticeable when climbing stairs and combing hair. The weakness improves after brief exercise. She also has bladder incontinence for the past 4 weeks and was given an anticholinesterase agent with no improvement. What is the most likely cause of the symptoms?", "answer": "Paraneoplastic syndrome from small cell carcinoma of the lung", "options": {"A": "Duchenne muscular dystrophy", "B": "Hypothyroidism", "C": "Myasthenia gravis", "D": "Paraneoplastic syndrome from small cell carcinoma of the lung"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old woman schedules", "appointment", "physician", "evaluation of weight loss", "weakness", "weakness", "more", "climbing stairs", "combing hair", "weakness improves", "brief exercise", "bladder incontinence", "past 4 weeks", "given", "anticholinesterase agent", "improvement", "most likely cause", "symptoms"]}
{"question": "A 3-month-old boy presents to his pediatrician with persistent diarrhea, oral candidiasis, and signs and symptoms suggestive of respiratory syncytial virus (RSV) pneumonia. His weight is in the 10th percentile. He is being evaluated for an immunodeficiency disease. Laboratory results for the HIV are negative by PCR. Which of the following is the most likely cause of these findings in this patient?", "answer": "Defective T cell function", "options": {"A": "Defective T cell function", "B": "Grossly reduced levels of B cells", "C": "Defective isotype switching", "D": "Selective IgA deficiency"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 month old boy presents", "pediatrician", "persistent diarrhea", "oral candidiasis", "signs", "symptoms suggestive of respiratory syncytial virus", "pneumonia", "weight", "percentile", "evaluated", "immunodeficiency disease", "Laboratory results", "HIV", "negative", "PCR", "following", "most likely cause", "findings", "patient"]}
{"question": "A 53-year-old man with recurrent pancreatic adenocarcinoma is enrolled in a clinical trial for a novel chemotherapeutic agent that his physician believes may be beneficial to his condition. The novel drug was previously tested in a small population and is now undergoing a larger phase 3 trial in preparation for FDA approval. A dose-response trial had the following results:\n\n10 mg dose - 6/59 patients demonstrated improvement\n20 mg dose - 19/49 patients demonstrated improvement\n30 mg dose - 26/53 patients demonstrated improvement\n40 mg dose - 46/51 patients demonstrated improvement\n\nThe same trial also had the following safety profile:\n\n20 mg dose - 5/49 patients had a treatment related adverse event\n40 mg dose - 11/51 patients had a treatment related adverse event\n60 mg dose - 15/42 patients had a treatment related adverse event\n80 mg dose - 23/47 patients had a treatment related adverse event\n100 mg dose - 47/52 patients had a treatment related adverse event\n\nBased on this study, which of the following represents the most likely therapeutic index for this novel chemotherapeutic agent?", "answer": "2.67", "options": {"A": "0.375", "B": "0.5", "C": "2.5", "D": "2.67"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "recurrent pancreatic adenocarcinoma", "enrolled", "clinical trial", "novel chemotherapeutic agent", "physician", "condition", "novel drug", "tested", "small population", "now", "larger phase 3 trial", "preparation", "FDA approval", "dose-response trial", "following results", "10 mg dose", "6 59 patients", "improvement 20 mg dose", "patients", "improvement 30 mg dose", "patients", "improvement 40 mg dose", "46", "patients", "improvement", "same trial", "following safety profile", "20 mg dose", "patients", "treatment related adverse event 40 mg dose", "patients", "treatment related adverse event 60 mg dose", "patients", "treatment related adverse event 80 mg dose", "23", "patients", "treatment related adverse event 100 mg dose", "patients", "treatment related adverse event", "Based", "study", "following represents", "most likely therapeutic index", "novel chemotherapeutic agent"]}
{"question": "A 67-year-old male is seen by neurology after he was noticed to be speaking strangely by his family. After acute treatment with tissue plasminogen activator (tPA), the patient is able to recover most of his speech. Subsequent neurologic exam finds that the patient is fluent while speaking and is able to comprehend both one and two step instructions. Noticeably the patient remains unable to complete tasks involving verbal repetition. Residual damage to which of the following structures is most likely responsible for this patient's syndrome?", "answer": "Arcuate fasciculus", "options": {"A": "Arcuate fasciculus", "B": "Superior temporal gyrus", "C": "Inferior frontal gyrus + superior temporal gyrus", "D": "Arcuate fasciculus + inferior frontal gyrus + superior temporal gyrus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old male", "seen", "neurology", "to", "speaking", "family", "acute treatment", "tissue plasminogen activator", "patient", "able to recover most", "speech", "Subsequent neurologic exam finds", "patient", "fluent", "speaking", "able to", "one", "two step instructions", "patient", "unable to complete tasks involving verbal repetition", "Residual damage", "following structures", "most likely responsible", "patient's syndrome"]}
{"question": "A 27-year-old woman presents to the office with concerns about her long struggle with her physical appearance since adolescence. She says she has always been \"large\" and was constantly targeted by her classmates and coworkers for being so. Her main concern at the moment is her acne and unwanted facial hair on her upper lip, for which she often visits a local spa. She has tried numerous diet plans, exercise regimens, and cosmetic products with little to no effect. Recently, she underwent a glucose tolerance test that showed a plasma glucose level of 160 mg/dL (8.9 mmol/L) after 2 hours of a 75 g dose of oral glucose. She has a family history of type 2 diabetes mellitus and a menstrual cycle that occurs every 45 days. Her pulse is 72/min and the blood pressure is 138/80 mm Hg. On physical examination, her height is 160 cm (5 ft 3 in) and her weight is 85 kg (187 lb), and she has severe inflammatory acne over the cheeks and forehead and dark coarse hairs on the back. What is the most likely diagnosis of this patient?", "answer": "Polycystic ovarian syndrome (PCOS)", "options": {"A": "Hypothyroidism", "B": "Idiopathic hirsutism", "C": "Polycystic ovarian syndrome (PCOS)", "D": "Ovarian hyperthecosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old woman presents", "office", "concerns", "long", "physical appearance", "adolescence", "always", "large", "constantly targeted", "classmates", "coworkers", "so", "main concern", "acne", "unwanted facial hair", "upper lip", "often visits", "local spa", "numerous diet plans", "exercise regimens", "cosmetic products", "little", "no effect", "Recently", "glucose tolerance test", "showed", "plasma glucose level", "160 mg", "mmol/L", "2 hours", "75 g dose", "oral glucose", "family history of type 2 diabetes mellitus", "menstrual cycle", "occurs", "days", "pulse", "72 min", "blood pressure", "80 mm Hg", "physical examination", "height", "5 ft", "weight", "85 kg", "severe inflammatory acne", "cheeks", "forehead", "dark coarse hairs", "back", "most likely diagnosis", "patient"]}
{"question": "А 43-уеаr-old mаn рrеѕеntѕ wіth tіnglіng аnd numbnеѕѕ of the lowеr lіmbѕ for 2 wееkѕ. Не also сomрlаіnѕ of реrѕіѕtеnt раіn in his legs whісh is not relieved by over-the-counter analgesics. Past medical history is significant for type 2 dіаbеtes mellitus for 2 уеаrѕ, inconsistently managed with mеtformіn аnd glіmеріrіdе. Оn physical ехаmіnаtіon, thеrе іѕ dесrеаѕеd ѕеnѕаtіon to pain in both lower lіmbs, but deep tеndon rеflехеѕ аrе іntасt. Ніѕ vіtаl ѕіgnѕ include: blood рrеѕѕurе 122/84 mm Нg, tеmреrаturе 36.7°C (98.1°F), and rеѕріrаtorу rаtе 10/mіn. His ankle-brachial pressure index (ABPI) on the right side is 1.1. His blood sugar analyses are as follows:\nFasting 141 mg/ dL\n2 hours Post-Prandial 235 mg/ dL\nHbA1c 8.1%\nWhich of the following is the best measure to prevent the progression of the symptoms present in this patient?", "answer": "Strict blood glucose control", "options": {"A": "Use of atorvastatin", "B": "Femoro-Ileal artery bypass", "C": "Strict blood glucose control", "D": "Lower limb amputation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["r old mn", "2 wk", "legs", "not relieved by over-the-counter analgesics", "Past medical history", "significant", "type 2", "r", "managed", "physical", "thr", "drd", "pain", "lower", "deep", "r ntt", "gn include", "blood", "84 mm g", "36", "98", "rt 10 mn", "ankle-brachial pressure index", "right side", "1.1", "blood sugar", "follows", "Fasting", "mg", "dL hours Post-Prandial", "8.1", "following", "best measure to prevent", "progression", "symptoms present", "patient"]}
{"question": "A one-day-old male is evaluated in the hospital nursery for bilious vomiting. The patient has urinated multiple times since birth but has not yet passed meconium. He was born at 38 weeks gestation to a 36-year-old gravida 3 via vaginal delivery. The pregnancy was complicated by gestational diabetes. The patient’s mother received routine prenatal care and declined first trimester screening. She subsequently underwent a quadruple screen at 15 weeks gestation that demonstrated decreased maternal serum alpha-fetoprotein (AFP), increased beta-hCG, decreased unconjugated estriol, and increased inhibin A. Her last ultrasound prior to onset of labor demonstrated an amniotic fluid index (AFI) of 28 cm. The patient’s two older siblings are both healthy. The patient’s temperature is 97.8°F (36.6°C), blood pressure is 58/37 mmHg, pulse is 166/min, and respirations are 38/min. On physical exam, the patient is in moderate distress. His abdomen is firm and distended with hypoactive bowel sounds.\n\nWhich of the following is the most likely etiology of this fetus’s presentation?", "answer": "Duodenal atresia", "options": {"A": "Duodenal atresia", "B": "Meconium ileus", "C": "Necrotizing enterocolitis", "D": "Pyloric stenosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["one-day old male", "evaluated", "hospital nursery", "bilious vomiting", "patient", "multiple times", "birth", "not", "passed meconium", "born", "weeks gestation", "36 year old gravida 3", "vaginal delivery", "pregnancy", "complicated", "gestational diabetes", "patients mother received routine prenatal care", "first trimester screening", "quadruple screen", "weeks gestation", "decreased maternal serum alpha-fetoprotein", "increased beta-hCG", "decreased unconjugated estriol", "increased inhibin A", "last ultrasound prior to onset of labor", "amniotic fluid index", "patients two older siblings", "healthy", "patients temperature", "97", "36", "blood pressure", "58", "mmHg", "pulse", "min", "respirations", "min", "physical exam", "patient", "moderate distress", "abdomen", "firm", "distended", "hypoactive bowel sounds", "following", "most likely etiology", "presentation"]}
{"question": "A healthy 23-year-old male is undergoing an exercise stress test as part of his physiology class. If blood were to be sampled at different locations before and after the stress test, which area of the body would contain the lowest oxygen content at both time points?", "answer": "Coronary sinus", "options": {"A": "Inferior vena cava", "B": "Coronary sinus", "C": "Pulmonary artery", "D": "Pulmonary vein"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 23 year old male", "exercise stress test", "part of", "physiology class", "blood", "to", "sampled", "different locations", "stress test", "area", "body", "contain", "lowest oxygen content", "time points"]}
{"question": "A 45-year-old G5P4105 presents to her gynecologist’s office with six months of increasingly heavy periods. She now soaks one super absorbent tampon every two hours for five days each cycle. Her cycles have also become irregular, with intermenstrual bleeding for the last two months. She now experiences significant dysmenorrhea, requiring 400 mg ibuprofen every four hours for the majority of each menses. In addition, she reports new onset mild dyspareunia with intercourse and a “heavy feeling” in her pelvis. She has also noticed increased urinary frequency but denies bowel changes. The patient has a past medical history of obesity and type II diabetes on metformin. Her last child was born four years ago, and she has had five spontaneous vaginal deliveries. At this office visit, temperature is 98.5°F (36.9°C), blood pressure is 137/84 mmHg, pulse is 87/min, and respirations are 14/min. Which of the following physical exam findings is most likely to be present in this patient?", "answer": "Globular 10-week sized uterus", "options": {"A": "Globular 10-week sized uterus", "B": "Adnexal mass", "C": "Irregular 14-week sized uterus", "D": "No remarkable physical exam finding"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "presents", "gynecologists office", "six months", "heavy periods", "now soaks one", "absorbent tampon", "two hours", "five", "cycle", "cycles", "irregular", "intermenstrual bleeding", "two months", "now experiences significant dysmenorrhea", "400 mg ibuprofen", "four hours", "majority", "menses", "addition", "reports new onset mild dyspareunia", "intercourse", "heavy feeling", "pelvis", "increased urinary frequency", "denies bowel changes", "patient", "past medical", "type II diabetes", "metformin", "last child", "born four years", "five spontaneous vaginal deliveries", "office visit", "temperature", "98", "36", "blood pressure", "84 mmHg", "pulse", "87 min", "respirations", "min", "following physical exam findings", "most likely to", "present", "patient"]}
{"question": "A man is brought into the emergency department by the police department. The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless. On exam, the man is behaving erratically. His vitals are all within normal limits. He appears confused and has a slurred speech. On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds. Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2. His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7. His urinalysis is shown in Figure 1. Blood salicylate levels return as normal. While you await other diagnostic tests, which of the following should be administered next to treat this patient?", "answer": "Fomepizole", "options": {"A": "Ethanol", "B": "Naltrexone", "C": "Naloxone", "D": "Fomepizole"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["man", "brought", "emergency department", "police department", "state", "man", "arrested multiple times", "public alcohol intoxication", "recently", "homeless", "exam", "man", "normal limits", "appears confused", "slurred speech", "gait exam", "patient", "ataxic", "stand", "support", "more", "seconds", "Labs return", "following values", "Na", "K 4", "Cl", "Cr 2", "ABG", "pH", "3", "PaO2", "HCO3", "urinalysis", "shown", "Blood salicylate levels return", "normal", "diagnostic tests", "following", "administered next to treat", "patient"]}
{"question": "A medical research study is evaluating an investigational novel drug (medication 1) compared with standard therapy (medication 2) in patients presenting to the emergency department with myocardial infarction (MI). The study enrolled a total of 3,000 subjects, 1,500 in each study arm. Follow-up was conducted at 45 days post-MI. The following are the results of the trial:\nEndpoints Medication 1 Medication 2 P-Value\nPrimary: death from cardiac causes 134 210 0.03\nSecondary: hyperkalemia 57 70 0.4\nWhat is the number needed to treat (NNT) for the primary endpoint of death from cardiac causes? (Round to the nearest whole number.)", "answer": "20", "options": {"A": "5", "B": "16", "C": "20", "D": "50"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["medical", "evaluating", "investigational novel drug", "medication 1", "compared", "standard therapy", "medication 2", "patients presenting", "emergency department", "myocardial infarction", "study enrolled", "total", "subjects", "1 500", "study arm", "Follow-up", "conducted", "days post-MI", "following", "results", "trial", "Endpoints Medication", "2 P-Value Primary", "death", "cardiac", "0.03 Secondary", "hyperkalemia 57 70 0.4", "number needed", "treat", "primary endpoint", "death", "cardiac causes", "Round", "nearest whole number"]}
{"question": "A 55-year-old man comes to the physician because of a 6-week history of tingling pain in the sole of his right foot when he raises it above chest level during exercises. He reports that he started exercising regularly 2 months ago and that his right calf cramps when he uses the incline feature on the treadmill, forcing him to take frequent breaks. The pain completely disappears after resting for a few minutes. He has an 8-year history of type 2 diabetes mellitus. He has smoked two packs of cigarettes daily for 34 years. His only medication is metformin. His pulse is 82/min, and blood pressure is 170/92 mm Hg. Straight leg raise test elicits pallor and tingling pain in the right foot. There is no pain in the back. His muscle strength is normal. Femoral pulses are palpable; right pedal pulses are absent. Which of the following is the most likely diagnosis?", "answer": "Femoropopliteal artery stenosis", "options": {"A": "Femoropopliteal artery stenosis", "B": "Acute thrombosis of right popliteal vein", "C": "Lumbar spinal stenosis", "D": "Aortoiliac artery stenosis\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man", "physician", "week history", "tingling pain", "sole of", "right foot", "chest level", "exercises", "reports", "started exercising", "months", "right", "uses", "feature", "treadmill", "forcing", "to take frequent breaks", "pain completely", "resting", "minutes", "year history of type 2 diabetes mellitus", "smoked two packs", "cigarettes daily", "years", "only medication", "metformin", "pulse", "min", "blood pressure", "mm Hg", "Straight leg raise test elicits pallor", "tingling pain in", "right foot", "pain in", "back", "muscle strength", "normal", "Femoral pulses", "palpable", "right pedal pulses", "absent", "following", "most likely diagnosis"]}
{"question": "A 29-year-old primigravid woman at 35 weeks' gestation is admitted to the hospital in labor. She has no history of serious medical illness. She has had an uncomplicated pregnancy. Her last ultrasound at 22 weeks' gestation was normal. On admission, fetal heartbeats cannot be detected by fetal doppler monitor. Ultrasound shows decreased amniotic fluid levels and no evidence of fetal movement, respiration, or heart activity. The patient gives birth to a 2296 g (5 lb 1 oz) male infant. Physical examination shows no signs of life. There are no visible malformations. The placenta is unremarkable. Which of the following is the most appropriate next step in management?", "answer": "Recommend autopsy of the infant", "options": {"A": "Perform karyotyping of amniotic fluid", "B": "Recommend autopsy of the infant", "C": "Obtain photographs, x-ray imaging, and MRI", "D": "Obtain consent for parental genetic testing"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old primigravid woman", "35 weeks", "gestation", "admitted", "hospital", "labor", "history of serious medical illness", "uncomplicated pregnancy", "last ultrasound", "weeks", "gestation", "normal", "On admission", "fetal heartbeats", "detected", "fetal doppler monitor", "Ultrasound shows decreased amniotic fluid levels", "evidence", "fetal movement", "respiration", "heart activity", "patient gives birth", "g", "1 oz", "male infant", "Physical examination shows", "signs", "life", "visible malformations", "placenta", "unremarkable", "following", "most appropriate next step", "management"]}
{"question": "A 67-year-old man is hospitalized after several days of fever and increasing shortness of breath. Respiratory viral panel returns positive for influenza A and the patient is started on a standard five day course of oseltamivir. Despite therapy, his shortness of breath continues to worsen and his oxygen saturation decreases to the point where ICU transfer and intubation are required. Chest radiograph shows bilateral infiltrates. Clinical criteria are consistent with development of Acute Respiratory Distress Syndrome (ARDS). After several weeks of supportive therapy, the patient improves with lung function returning to near normal. Which of the following processes is involved in the regeneration of alveolar lining after damage to alveoli occurs?", "answer": "Proliferation of surfactant-secreting cells", "options": {"A": "Sweeping of debris out of the alveoli by ciliated cells", "B": "Excess mucus production by goblet cells", "C": "Proliferation of surfactant-secreting cells", "D": "Proliferation of club cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "hospitalized", "days", "fever", "increasing shortness of breath", "Respiratory viral panel returns positive", "influenza A", "patient", "started", "standard five day course", "oseltamivir", "therapy", "shortness of breath continues to worsen", "oxygen saturation decreases to", "point", "ICU transfer", "intubation", "required", "Chest radiograph shows bilateral infiltrates", "Clinical criteria", "consistent with development", "Acute Respiratory Distress Syndrome", "several weeks", "supportive", "patient improves", "lung function returning", "normal", "following processes", "involved", "regeneration", "alveolar lining", "damage", "alveoli occurs"]}
{"question": "A 65-year-old male is treated for anal carcinoma with therapy including external beam radiation. How does radiation affect cancer cells?", "answer": "Induces breaks in double-stranded DNA", "options": {"A": "Induces the formation of thymidine dimers", "B": "Induces the formation of disulfide bonds", "C": "Induces deamination of cytosine", "D": "Induces breaks in double-stranded DNA"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old male", "treated", "anal carcinoma", "therapy including external beam radiation", "radiation affect cancer cells"]}
{"question": "A 56-year-old man with a history of hypertension presents to his physician with progressive fatigue and new onset muscle cramps. He has had no recent changes to his medication regimen, which includes hydrochlorothiazide, lisinopril, and amlodipine. His temperature is 98.0°F (36.7°C), blood pressure is 174/111 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. The patient's cardiopulmonary and abdominal exams are unremarkable. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 138 mEq/L\nCl-: 100 mEq/L\nK+: 3.3 mEq/L\nHCO3-: 33 mEq/L\nBUN: 20 mg/dL\nGlucose: 129 mg/dL\n\nWhat is the most likely underlying etiology of this patient's hypertension?", "answer": "Aldosterone excess", "options": {"A": "Aldosterone excess", "B": "Catecholamine-secreting mass", "C": "Cortisol excess", "D": "Impaired kidney perfusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "history of hypertension presents", "physician", "progressive fatigue", "new onset muscle cramps", "recent changes", "medication regimen", "includes hydrochlorothiazide", "lisinopril", "amlodipine", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "70 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient's cardiopulmonary", "abdominal exams", "unremarkable", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "3.3 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "mg/dL", "most likely underlying etiology", "patient's hypertension"]}
{"question": "A 65-year-old man comes to the physician because of a 1-week history of yellowish discoloration of his skin and generalized pruritus. Examination shows jaundice of the skin and scleral icterus. Urinalysis shows an elevated concentration of bilirubin and a low concentration of urobilinogen. Which of the following is the most likely underlying cause of these findings?", "answer": "Defective hepatic bile excretion", "options": {"A": "Absent UDP-glucuronosyltransferase activity", "B": "Increased hemoglobin breakdown", "C": "Increased intestinal bilirubin reabsorption", "D": "Defective hepatic bile excretion"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old man", "physician", "of", "1-week history", "discoloration", "skin", "generalized pruritus", "Examination shows jaundice", "skin", "scleral icterus", "Urinalysis shows", "elevated concentration", "bilirubin", "low concentration", "urobilinogen", "following", "most likely underlying cause", "findings"]}
{"question": "A 72-year-old woman is brought to the physician by her daughter because of a 6-month history of worsening short-term memory deficits and social withdrawal. Treatment with galantamine is initiated. Two weeks later, the patient develops vomiting, mild crampy abdominal pain, and watery, nonbloody diarrhea. Which of the following is the most appropriate pharmacotherapy?", "answer": "Atropine", "options": {"A": "Bethanechol", "B": "Metoclopramide", "C": "Atropine", "D": "Oxybutynin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old woman", "brought", "physician", "daughter", "month history", "worsening short-term memory deficits", "social withdrawal", "Treatment", "galantamine", "initiated", "Two weeks later", "patient", "vomiting", "mild crampy abdominal pain", "watery", "diarrhea", "following", "most appropriate pharmacotherapy"]}
{"question": "A 61-year-old man with schizophrenia in a locked inpatient psychiatry unit was observed making an unusual smacking motion with his lips, pursing his mouth, and blinking excessively. These symptoms started slowly about 2 weeks ago and have become more pronounced, but they do not seem to bother the patient. He resides in an inpatient psychiatric facility where he has been successfully treated with haloperidol for the past several months. His physical exam and vitals are within normal limits. Which of the following accurately describes his symptoms?", "answer": "Tardive dyskinesia", "options": {"A": "Tardive dyskinesia", "B": "Acute dystonia", "C": "Pseudoparkinsonism", "D": "Palsy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["61 year old man", "schizophrenia", "locked inpatient psychiatry unit", "observed making", "unusual smacking motion", "lips", "mouth", "blinking excessively", "symptoms started slowly", "weeks", "more", "not", "to", "patient", "resides", "inpatient psychiatric facility", "treated with haloperidol", "past", "months", "physical exam", "normal limits", "following", "symptoms"]}
{"question": "A 17-year-old football player with no significant past medical history, social history, or family history presents to his pediatrician with itching in his groin. He says this started during summer workouts leading up to this season. He denies having any rash anywhere else on his body. The blood pressure is 123/78 mm Hg, pulse is 67/min, respiratory rate is 15/min, and temperature is 38.1°C (98.7°F). Physical examination reveals an erythematous, well-demarcated patch with peripheral scale on the left thigh, pubic region, and perineum. There is no apparent scrotal involvement with the rash. How can you confirm the suspected diagnosis?", "answer": "KOH examination of lesion scrapings", "options": {"A": "KOH examination of lesion scrapings", "B": "Nikolsky's sign on physical exam", "C": "Gram stain of skin scrapings", "D": "AFB stain of skin scrapings"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old football", "significant past medical history", "social history", "family history presents", "pediatrician", "itching", "groin", "started", "summer", "leading", "season", "denies", "rash", "else", "body", "blood pressure", "mm Hg", "pulse", "67 min", "respiratory rate", "min", "temperature", "98", "Physical examination reveals", "erythematous", "well", "patch", "peripheral scale", "left thigh", "pubic region", "perineum", "apparent scrotal involvement with", "rash", "confirm", "suspected diagnosis"]}
{"question": "An otherwise healthy 26-year-old man comes to the physician for medication counseling after recently being diagnosed with schizophrenia. Risperidone therapy is initiated. This patient is at increased risk for which of the following adverse effects?", "answer": "Gynecomastia", "options": {"A": "Agranulocytosis", "B": "Shortened QT interval", "C": "Gynecomastia", "D": "Weight loss"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "medication counseling", "recently", "diagnosed", "schizophrenia", "Risperidone therapy", "initiated", "patient", "increased risk", "following adverse effects"]}
{"question": "A 15-year-old woman presents with fever, altered mental status and a petechial rash on her lower extremities and back since yesterday evening. She also says she has been nauseous for the past 3 hours and has vomited twice. The patient mentions she has had heavy menstrual bleeding for the past few days. Her blood pressure is 95/80 mm Hg and her temperature is 40.0°C (104.0°F). On physical examination, the patient appears diaphoretic. A pelvic examination reveals a tampon in her vagina. Binding and activation of which of the following T cell receptors is responsible for this patient’s most likely condition?", "answer": "Variable β-sequence of the T cell receptor", "options": {"A": "B7 receptor", "B": "Variable β-sequence of the T cell receptor", "C": "CD3", "D": "IgCAM"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "fever", "altered mental status", "petechial rash", "lower extremities", "back", "evening", "nauseous", "past", "hours", "vomited twice", "patient", "heavy menstrual bleeding", "past", "days", "blood pressure", "95 80 mm Hg", "temperature", "40", "physical examination", "patient appears diaphoretic", "pelvic examination reveals", "tampon in", "vagina", "Binding", "activation", "following T cell receptors", "responsible", "patients", "likely condition"]}
{"question": "A 2-year-old boy is brought to the physician for evaluation of pallor and increasing lethargy for 2 days. One week ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since subsided. The patient's father states that they returned early from a 6-week roadtrip in Mexico because of these symptoms. His parents have been giving him oral rehydration solution. His immunizations are up-to-date. He appears pale. His temperature is 38.4°C (101.1°F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm Hg. Examination shows scleral icterus. The abdomen is soft and nontender; there is no rebound or guarding. Bowel sounds are hyperactive. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 8.5 g/dL\nMean corpuscular volume 94 μm3\nLeukocyte count 18,000/mm3\nPlatelet count 45,000/mm3\nProthrombin time 12 sec\nPartial thromboplastin time 34 sec\nSerum\nUrea nitrogen 28 mg/dL\nCreatinine 1.6 mg/dL\nBilirubin\nTotal 2.5 mg/dL\nDirect 0.1 mg/dL\nLactate dehydrogenase 1658 U/L\nA blood smear shows schistocytes. Which of the following is the most likely diagnosis?\"", "answer": "Hemolytic uremic syndrome", "options": {"A": "Henoch-Schönlein Purpura", "B": "Thrombotic thrombocytopenic purpura", "C": "Hemolytic uremic syndrome", "D": "Immune thrombocytopenic purpura"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["2 year old boy", "brought", "physician", "evaluation", "pallor", "increasing lethargy", "2", "One", "experienced abdominal pain", "vomiting", "bloody diarrhea", "since", "patient", "ather  tates ", "eturned  arly ", "eek ", "exico ", "ymptoms.", "arents ", "iving ", "ral rehydration solution.", "mmunizations ", "ate.", "ppears  ale.", "emperature ", "C ", "ulse ", "in,", "espirations ", "5/ in,", "lood pressure ", "5/ 0  m Hg.", "xamination  hows  cleral icterus.", "bdomen ", "oft ", "ontender;", "uarding.", "owel sounds ", "yperactive.", "xamination  hows ", "bnormalities.", "aboratory studies  how:", "emoglobin ", "/", "ean corpuscular volume ", "3  eukocyte  8,", "latelet count ", "rothrombin time  2  ec  artial thromboplastin time ", "erum  rea nitrogen  8  g/", "reatinine ", "  g/", "otal ", "irect  .1  g/dL  actate dehydrogenase ", "/  ", "lood smear  hows  chistocytes.", "ollowing ", "ost likely  iagnosis?"]}
{"question": "A 17-year-old girl is referred by her dentist for a suspected eating disorder. She has been visiting the same dentist since childhood and for the past 2 years has had at least 2 visits for dental caries. She eventually admitted to him that she regularly induces vomiting by putting her fingers down her throat. She says she has been doing this for the last few years and purging at least once a week. More recently, she has been inducing emesis more often and even looked into diuretics as she feels that she is gaining more and more weight compared to her ‘skinny friends’. Her BMI is at the 50th percentile for her age and sex. Which of the following features is most consistent with this patient’s condition?", "answer": "Patients with this disorder are not further sub-typed", "options": {"A": "Patients with this disorder are not further sub-typed", "B": "Patients do not usually initiate treatment", "C": "Patients can have a history of both anorexia and bulimia", "D": "Patients will typically have a BMI between 17–18.5 kg/m2"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "referred by", "dentist", "suspected eating disorder", "visiting", "same dentist", "childhood", "past", "years", "visits", "dental caries", "admitted", "induces vomiting", "putting", "fingers", "throat", "last", "years", "purging", "week", "recently", "inducing emesis", "often", "looked", "diuretics", "feels", "gaining more", "more weight compared", "friends", "BMI", "50th percentile", "age", "sex", "following features", "most consistent with", "patients condition"]}
{"question": "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?", "answer": "Salmonella typhi", "options": {"A": "Giardia lamblia", "B": "Schistosoma mansoni", "C": "Salmonella typhi", "D": "Clostridium perfringens"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "father", "fever", "chills", "abdominal pain", "non bloody diarrhea", "symptoms began one week", "several days", "low-grade fever", "constipation", "returned", "Indonesia 2 weeks", "spent", "summer", "grandparents", "temperature", "3C", "Examination shows diffuse abdominal tenderness", "mild hepatosplenomegaly", "faint salmon colored maculopapular rash", "trunk", "abdomen", "following", "most likely causal organism"]}
{"question": "A 22-year-old female college student is treated with metronidazole after presenting to student health services with itching, discharge, and pain in her vagina. At a party shortly afterward she experiences facial flushing, nausea, tachycardia, dyspnea, headache, and abdominal cramps after consuming alcohol. Serum levels of which of the following are likely elevated in this patient following alcohol consumption:", "answer": "Acetaldehyde", "options": {"A": "Acetaldehyde", "B": "Uric acid", "C": "Cytochrome P-450 enzymes", "D": "Amylase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female college student", "treated with metronidazole", "presenting", "student health services", "itching", "discharge", "pain in", "vagina", "party", "experiences facial flushing", "nausea", "tachycardia", "dyspnea", "headache", "abdominal cramps", "alcohol", "Serum levels", "following", "likely elevated", "patient following alcohol consumption"]}
{"question": "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:\nErythrocyte count 3.9 million/mm3\nHb 11.1 g/dL\nHCT 32%\nReticulocyte count 0.2%\nMCV 90 fL\nPlatelet count 210,000/mm3\nLeukocyte count 8,100/mm3\nWhich of the following tests is required to investigate the cause of the patient’s laboratory findings?", "answer": "No tests required", "options": {"A": "Serum iron level", "B": "Serum B12 level", "C": "Transferrin", "D": "No tests required"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old primigravida presents", "regular prenatal visit", "weeks gestation", "increased fatigability", "well", "takes folic acid", "iron", "vitamin", "supplementation", "vital signs", "follows", "blood pressure", "70 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "physical examination", "unremarkable", "complete blood count results", "Erythrocyte", "mm3 Hb", "g", "HCT", "Reticulocyte", "0.2", "MCV 90 fL Platelet count", "Leukocyte", "100", "following tests", "required to investigate", "cause", "patients laboratory findings"]}
{"question": "An 80-year-old man is transferred from a step-down unit to a med-surg floor in the hospital. He had undergone a successful hernia surgery 14 hours ago. Before the surgery, he was pre-treated with atropine, scopolamine, and morphine and recovered well in the PACU after the surgery. There were no complications in the step-down unit and the patient continued to recover. On the med-surg floor, his temperature is 36.8°C (98.2°F), the heart rate is 98/min, the respiratory rate is 15/min, the blood pressure is 100/75 mm Hg, the oxygen saturation is 90%. On physical exam, he is a well-developed, obese man. His heart has a regular rate and rhythm and his lungs are clear to auscultation bilaterally. His incision site is clean, dry, and intact with an appropriate level of swelling and erythema. During the physical, the patient mentions some discomfort in his abdomen and pelvis and during a records review it is noted that he has not passed urine in the PACU, step-down unit, or since arriving on the med-surg floor. A bladder scan is inconclusive due to body habitus. What is the next best step in the treatment of this patient?", "answer": "Insert a ‘straight cath’ into the patient’s bladder", "options": {"A": "Insert a ‘straight cath’ into the patient’s bladder", "B": "Aggressive IV fluids", "C": "Digital rectal exam", "D": "Renal ultrasound"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["80 year old man", "transferred", "step-down unit", "med surg floor", "hospital", "successful hernia surgery", "hours", "surgery", "pre treated with atropine", "scopolamine", "morphine", "recovered well", "PACU", "surgery", "complications", "step-down unit", "patient continued to recover", "med surg floor", "temperature", "36", "98", "heart rate", "98 min", "respiratory rate", "min", "blood pressure", "100 75 mm Hg", "oxygen saturation", "90", "physical exam", "well", "obese man", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "incision site", "clean", "dry", "intact", "appropriate level", "swelling", "erythema", "physical", "patient", "discomfort", "abdomen", "pelvis", "records review", "noted", "not passed urine", "PACU", "step-down unit", "since", "med surg floor", "bladder scan", "inconclusive due to body", "next best step", "treatment", "patient"]}
{"question": "A healthy 19-year-old man presents to his primary care provider complaining of painless “blisters” in his mouth. He reports that he noticed a white film on his tongue and the sides of his mouth 2 days ago while brushing his teeth. The film was easily brushed off. He also complains of a bitter metallic taste in his mouth but otherwise denies pain, burning, dysphagia, or hoarseness. He is otherwise healthy and takes no medications. He is a competitive swimmer and has had 8 sexual partners in the past year. He intermittently uses barrier protection. On exam, he is well-appearing and in no acute distress. His oral examination demonstrates patches of white pseudomembranes that can be wiped away to reveal erythematous mucosa. A medication with which of the following mechanisms of action is most appropriate in this patient?", "answer": "Disruption of cell membrane permeability", "options": {"A": "Disruption of cell membrane permeability", "B": "Disruption of microtubule formation", "C": "Inhibition of 14-alpha-demethylase", "D": "Inhibition of beta-glucan synthase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old man presents", "primary care provider", "painless blisters", "mouth", "reports", "white film", "tongue", "sides", "mouth 2 days", "brushing", "teeth", "film", "easily brushed", "bitter metallic", "mouth", "denies pain", "burning", "dysphagia", "hoarseness", "healthy", "takes", "medications", "competitive swimmer", "sexual partners", "past year", "uses barrier protection", "exam", "well appearing", "acute distress", "oral examination demonstrates patches", "white pseudomembranes", "wiped", "to reveal erythematous mucosa", "medication", "of", "following mechanisms", "action", "most appropriate", "patient"]}
{"question": "A 56-year-old man presents to the clinic complaining of subacute back pain for the past month. The pain is described as a dull, constant ache that is worse at night. He could not recall any precipitating event except for an amateur weight-lifting competition that he participated in 2 months ago. Past medical history is significant for non-small cell lung cancer that was diagnosed and successfully treated. A PET scan 1 year ago demonstrated no recurrence. Physical exam was unremarkable except for some point tenderness along the lumbosacral area. What is the most likely imaging finding in this patient?", "answer": "Lytic lesions of the lumbar spine", "options": {"A": "Bulging disc impinging on lumbar spinal nerve", "B": "Lytic lesions of the lumbar spine", "C": "Narrowing of the lumbar disc space", "D": "Sacroilitis and fusion of the lumbar spine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "clinic", "of subacute back pain", "past month", "pain", "described", "dull", "constant ache", "worse", "night", "not recall", "precipitating event", "amateur weight-lifting competition", "months", "Past medical history", "significant", "non-small cell lung cancer", "diagnosed", "treated", "PET scan year", "recurrence", "Physical exam", "unremarkable", "point tenderness", "lumbosacral area", "most likely imaging finding", "patient"]}
{"question": "A 4-year-old boy is brought to the emergency department because of severe abdominal pain and bilious vomiting for 6 hours. He has not had bowel movements in the past 24 hours. He appears ill. His temperature is 37.8°C (100°F) and pulse is 122/min. Examination shows a distended abdomen. There is tenderness to palpation in the lower abdomen; guarding and rebound tenderness are present. Bowel sounds are decreased. An x-ray of the abdomen shows dilated loops of bowel. He has been accompanied by his 14-year-old brother. The surgeon recommends an emergency laparotomy. The parents are away visiting friends and cannot be reached. Which of the following is the most appropriate next best step in management?", "answer": "Perform emergency laparotomy", "options": {"A": "Get consent from the patient's brother", "B": "Get consent from the patient", "C": "Perform emergency laparotomy", "D": "Delay surgery until parental consent"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "emergency department", "severe abdominal", "bilious vomiting", "hours", "not", "bowel movements", "past 24 hours", "appears ill", "temperature", "pulse", "min", "Examination shows", "distended abdomen", "tenderness", "palpation", "lower abdomen", "guarding", "rebound tenderness", "present", "Bowel sounds", "decreased", "x-ray of", "abdomen shows dilated", "bowel", "year old brother", "surgeon recommends", "emergency laparotomy", "parents", "visiting friends", "reached", "following", "most appropriate next best step", "management"]}
{"question": "A 3-week-old male newborn is brought to the hospital because of poor weight gain since birth. He was born at 38 weeks' gestation via normal vaginal delivery. He weighed 3005 g (6 lb, 10 oz) at birth and currently weighs 2835 g (6 lb, 4 oz). He has been latching on and breastfeeding well since birth. His mother has a history of Graves' disease and underwent near-total thyroidectomy in the second trimester of her pregnancy after her symptoms could not be controlled with antithyroid drugs. She is currently receiving L-thyroxine therapy. The patient's temperature is 38.9°C (102°F), pulse is 176/min, and respirations are 42/min. He appears irritable. Examination shows a diaphoretic infant with a paucity of subcutaneous fat. There is swelling of the neck at the midline. Which of the following is the most likely cause?", "answer": "Transplacental passage of TSH receptor antibodies", "options": {"A": "Transplacental passage of thyroid peroxidase antibodies", "B": "Transplacental passage of TSH receptor antibodies", "C": "Transplacental viral infection", "D": "Opiate use in the mother"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 week old male newborn", "brought", "hospital", "poor weight gain", "birth", "born", "weeks", "gestation", "normal vaginal", "g", "10 oz", "birth", "currently", "g", "4 oz", "latching", "breastfeeding well", "birth", "mother", "history of Graves", "disease", "total thyroidectomy", "second trimester", "pregnancy", "symptoms", "not", "controlled", "drugs", "currently receiving L-thyroxine therapy", "patient's temperature", "pulse", "min", "respirations", "min", "appears irritable", "Examination shows", "diaphoretic infant", "subcutaneous fat", "swelling of the neck", "midline", "following", "most likely cause"]}
{"question": "A 57-year-old female with a past medical history of alcoholism presents to the emergency room vomiting bright red blood. She is accompanied by her partner, who reports that she had been complaining of black and tarry stools for the past several days. Vital signs are temperature 37 degrees celsius, heart rate 141 beats per minute, blood pressure 90/60, respiratory rate 20, and oxygen saturation 99% on room air. On physical examination, she has splenomegaly and a positive fluid wave. The remainder of her examination is within normal limits. The patient is stabilized with intravenous fluids, and her blood pressure improves. Subsequent emergent upper endoscopy reveals bleeding from the submucosal veins in the lower 1/3 of the esophagus, but no gastric bleed. In the endoscopy suite she also receives IV octreotide. After intervention and resolution of her acute bleed, which of the following pharmacologic agents is indicated?", "answer": "Nadalol", "options": {"A": "Phentolamine", "B": "Prazosin", "C": "Nifedipine", "D": "Nadalol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["57 year old female", "past medical presents", "emergency room vomiting bright red blood", "partner", "reports", "black", "tarry stools", "past", "days", "Vital signs", "temperature", "degrees celsius", "heart rate", "beats per minute", "blood pressure 90 60", "respiratory rate 20", "oxygen 99", "room air", "physical examination", "splenomegaly", "positive fluid wave", "examination", "normal limits", "patient", "stabilized", "intravenous fluids", "blood pressure improves", "Subsequent emergent upper endoscopy reveals bleeding", "submucosal veins", "lower", "esophagus", "gastric bleed", "endoscopy suite", "receives IV octreotide", "intervention", "resolution", "acute bleed", "following pharmacologic agents", "indicated"]}
{"question": "A 65-year-old man with a history of hypertension, obesity, and alcoholic cirrhosis is seen in clinic for follow-up. He feels well and currently drinks 5 glasses of wine each night. Medications include atenolol and lisinopril. On physical exam, temperature is 98.1 deg F (36.7 deg C), blood pressure is 151/82 mmHg, pulse is 71/min, and respirations are 14/min. He has spider angiomata on his chest; no asterixis, jaundice, ascites, or peripheral edema is noted. Screening ultrasound reveals a new liver nodule, and follow up CT demonstrates a 2 cm right hepatic lobe lesion with enhancement in the arterial phase. No hypodense attenuation is seen on the venous or delayed phase. What is the next step in management?", "answer": "Proceed with liver biopsy", "options": {"A": "Proceed with liver biopsy", "B": "Refer for surgical resection", "C": "Refer for radiofrequency ablation", "D": "Observe and get follow-up imaging in 3 months"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65-year-old man", "history of hypertension", "obesity", "alcoholic cirrhosis", "seen in clinic", "follow-up", "feels well", "currently drinks 5 glasses", "wine", "night", "Medications include atenolol", "lisinopril", "physical exam", "temperature", "98", "deg F", "36", "blood pressure", "mmHg", "pulse", "71 min", "respirations", "min", "spider angiomata", "chest", "asterixis", "jaundice", "ascites", "peripheral edema", "noted", "Screening ultrasound reveals", "new liver nodule", "follow up CT demonstrates", "2 cm right hepatic lesion", "enhancement", "arterial phase", "attenuation", "seen", "venous", "delayed phase", "next step", "management"]}
{"question": "A 66-year-old man is brought to the emergency room by his wife due to abdominal distension and persistent somnolence for the past 2 weeks. The patient’s wife says that he has been sleeping much more than usual for the past 5 days. His bowel and bladder habit have not changed. His past medical history is significant for alcoholic liver cirrhosis. His vital signs include: pulse 76/min, respiratory rate 15/min, temperature 38.0°C (100.4°F) and blood pressure 122/75 mm Hg. On physical examination, the patient is altered and not responsive to commands. Oriented x 0. The abdomen is significantly distended. Shifting dullness is present and a positive fluid wave can be elicited. Hyperreflexia and asterixis are noted. Laboratory findings are significant for the following:\nLaboratory test\nSodium 140 mEq/L\nPotassium 3.5 mEq/L\nChloride 97 mEq/L\nGlucose 90 mg/dL\nAmmonia 100 µg/dL (ref: 19-60 µg/dL)\nArterial blood gas\npH 7.4\npCO2 40 mm Hg\npO2 90 mm Hg\nHCO3 26 mEq/L\nAn abdominal ultrasound shows surface nodularity compatible with cirrhosis but no other changes aside from ascites. An upper GI endoscopy is performed which shows gastric varices with no signs of active bleeding. An MRI of the brain is insignificant. What is the most likely precipitating factor that led to this patient’s condition?", "answer": "Spontaneous bacterial peritonitis", "options": {"A": "Spontaneous bacterial peritonitis", "B": "Metabolic alkalosis", "C": "Portal vein thrombosis", "D": "Hypoglycemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old man", "brought", "emergency room", "wife due to abdominal distension", "persistent somnolence", "past 2 weeks", "patients wife", "sleeping much", "usual", "past", "days", "bowel", "bladder habit", "not changed", "past medical history", "significant", "alcoholic liver cirrhosis", "vital signs include", "pulse 76 min", "respiratory rate", "min", "temperature", "100 4F", "blood pressure", "75 mm Hg", "physical examination", "patient", "altered", "not responsive", "commands", "Oriented", "0", "abdomen", "distended", "Shifting dullness", "present", "positive fluid wave", "elicited", "Hyperreflexia", "asterixis", "noted", "Laboratory findings", "significant", "following", "Laboratory", "mEq", "Potassium", "Chloride", "Glucose", "mg dL Ammonia", "dL", "ref", "60 g/dL", "Arterial blood gas pH 7", "pCO2", "mm Hg pO2", "HCO3", "mEq/L", "abdominal ultrasound shows surface nodularity compatible", "cirrhosis", "changes", "ascites", "upper GI endoscopy", "performed", "shows gastric varices", "signs of active bleeding", "MRI of", "brain", "most likely precipitating factor", "led", "patients condition"]}
{"question": "A 27-year-old man presents to the emergency department after a motor vehicle collision. The patient was the front seat unrestrained driver in a head on collision. The patient’s echocardiogram (ECG) is notable only for sinus tachycardia. His temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient is given 2 liters of Ringer lactate solution and morphine. Initial workup demonstrates that the patient’s pulmonary capillary wedge pressure and troponins are elevated. The patient is currently complaining of chest pain. Physical exam is notable for an uncomfortable young man with bruising over his chest wall. Which of the following is the most likely diagnosis?", "answer": "Cardiac contusion", "options": {"A": "Cardiac contusion", "B": "Hemorrhage", "C": "Pulmonary contusion", "D": "Takotsubo cardiomyopathy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "emergency department", "motor vehicle collision", "patient", "front", "driver", "head", "collision", "patients echocardiogram", "notable only", "sinus tachycardia", "temperature", "99", "blood pressure", "58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "given 2 liters", "Ringer lactate solution", "morphine", "Initial workup demonstrates", "patients pulmonary capillary wedge pressure", "troponins", "elevated", "patient", "currently", "of chest pain", "Physical exam", "notable", "young man", "bruising", "chest wall", "following", "most likely diagnosis"]}
{"question": "A 56-year-old man presents to the emergency department for progressively worsening fatigue, malaise, fever, and abdominal pain. He reports that his symptoms began approximately 1 week ago and he has noticed episodes of diarrhea. He recently started melatonin and magnesium supplementation in hopes of improving his sleep. Medical history is significant for alcohol use disorder that required multiple hospital admissions for management of acute pancreatitis and cirrhosis. He states that he occasionally injects heroin intravenously. Temperature is 100°F (37.8°C), blood pressure is 105/70 mmHg, pulse is 92/min, and respirations are 17/min. Physical examination is significant for scleral icterus, hepatomegaly, ascites, and diffuse abdominal tenderness. Laboratory testing is significant for leukocytosis and metabolic acidosis. A paracentesis is performed and he is admitted into the hospital to receive intravenous cefotaxime and albumin. Ascitic fluid analysis demonstrates a polymorphonuclear cell count of 280 cells/mm^3, serum-ascites albumin gradient of 1.3 g/dL, and a culture positive for Escherichia coli sensitive to cefotaxime and ceftriaxone. On hospital day 2, the nurse reports that the patient is oliguric in the setting of constant fluid intake. Physical examination is unchanged. Laboratory testing is significant for a serum sodium of 131 mEq/L and creatinine of 1.8 mg/dL (it was 0.9 mg/dL on admission). Urine studies are significant for a low urine sodium level, without evidence of blood or protein. Since the hospital admission, he has not been started on any new medications. Which of the following will be the best treatment option for this patient?", "answer": "Liver transplantation", "options": {"A": "Adding dopamine to his treatment regimen", "B": "Adding lisinopril to his treatment regimen", "C": "Liver transplantation", "D": "Transjugular intrahepatic portosystemic shunting"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "worsening fatigue", "malaise", "fever", "abdominal pain", "reports", "symptoms began approximately", "week", "episodes of diarrhea", "recently started melatonin", "magnesium supplementation", "hopes", "improving", "sleep", "Medical history", "significant", "alcohol use disorder", "required multiple hospital", "management", "acute pancreatitis", "cirrhosis", "states", "occasionally injects heroin", "Temperature", "blood pressure", "70 mmHg", "pulse", "min", "respirations", "min", "Physical examination", "significant", "scleral icterus", "hepatomegaly", "ascites", "diffuse abdominal tenderness", "Laboratory testing", "significant", "leukocytosis", "metabolic acidosis", "paracentesis", "performed", "admitted", "hospital to receive intravenous cefotaxime", "albumin", "Ascitic demonstrates", "polymorphonuclear cell count", "cells mm", "serum-ascites albumin gradient", "g/dL", "culture positive", "Escherichia coli sensitive to cefotaxime", "ceftriaxone", "hospital", "nurse reports", "patient", "oliguric", "setting", "constant fluid intake", "Physical examination", "unchanged", "Laboratory testing", "significant", "serum sodium", "mEq/L", "creatinine", "1.8 mg/dL", "0.9 mg/dL on admission", "Urine studies", "significant", "low urine sodium level", "evidence", "blood", "protein", "hospital admission", "not", "started", "new medications", "following", "best treatment", "patient"]}
{"question": "A 29-year-old woman presents to the clinic after several months of weight loss. She noticed a 6.8 kg (15 lb) unintentional weight loss over the preceding several months. She has not changed her diet or exercise habits. She also reports feuding with her boyfriend over the temperature of their shared apartment, as she always feels warmer than he does. The vital signs include: heart rate 110/min and blood pressure 146/78 mm Hg. The physical exam is notable for warm and slightly moist skin. She also exhibits a fine tremor in her hands when her arms are outstretched. The urine pregnancy test is negative. Which of the following is the best single treatment option for this patient?", "answer": "Methimazole", "options": {"A": "Glucocorticoids", "B": "Methimazole", "C": "Propranolol", "D": "Radioiodine therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old woman presents", "clinic", "several months of weight loss", "kg", "unintentional weight loss", "preceding", "months", "not changed", "diet", "exercise habits", "reports", "boyfriend", "temperature", "shared apartment", "always feels warmer", "vital signs include", "heart rate", "min", "blood pressure", "mm Hg", "physical exam", "notable", "warm", "slightly moist skin", "exhibits", "fine", "hands", "arms", "urine pregnancy test", "negative", "following", "best single treatment", "patient"]}
{"question": "A 21-year-old man comes to the physician because of pruritus and a hypopigmented rash on his upper body for 5 days. He first noticed the symptoms after returning from a business trip last week in the Bahamas. While he was there, he visited a couple of beaches and went hiking with some coworkers. The rash initially started as a single lesion on his upper back but since then has extended to his shoulders. He has a history of type 1 diabetes mellitus controlled with an insulin pump. He works as an office manager and has no known exposure to melanocytotoxic chemicals. He has been sexually active with three female partners over the past year and uses condoms inconsistently. He is 183 cm (6 ft) tall and weighs 80 kg (176 lb); BMI is 23.9 kg/m2. His temperature is 37.2°C (99°F), pulse is 78/min, and blood pressure is 130/84 mm Hg. A photograph of the rash is shown. One month ago, his hemoglobin A1C was 7.8%. Which of the following is most likely to confirm the diagnosis?", "answer": "Potassium hydroxide preparation", "options": {"A": "Wood lamp examination", "B": "Skin culture", "C": "Potassium hydroxide preparation", "D": "Skin biopsy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["21-year-old man", "physician", "pruritus", "hypopigmented rash", "upper body", "5 days", "first", "symptoms", "returning", "business trip", "week", "Bahamas", "visited", "couple", "beaches", "hiking", "coworkers", "rash initially started", "single lesion", "upper back", "since then", "extended", "shoulders", "history of type 1 diabetes mellitus controlled", "insulin pump", "works", "office", "known exposure to", "chemicals", "sexually active", "three female partners", "past year", "uses condoms", "ft", "tall", "80 kg", "BMI", "23", "kg/m2", "temperature", "pulse", "min", "blood pressure", "84 mm Hg", "photograph", "rash", "shown", "One month", "hemoglobin A1C", "following", "most likely to confirm", "diagnosis"]}
{"question": "A 5-year-old female is brought to a speech therapist for continuing work on improving her communication skills. She is only able to verbalize two word sentences and has generalized developmental delay. When she was born it was noticed that she had a high pitched mewing cry and subsequent physical exam revealed microcephaly, prominent epicanthal folds, and a holosystolic murmur best heard in the left 5th intercostal space near the sternum. An abnormality of which of the following chromosomes is most likely responsible for this patient's disorder?", "answer": "5", "options": {"A": "5", "B": "7", "C": "18", "D": "21"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 year old female", "brought", "speech therapist", "continuing work", "improving", "communication skills", "only able to", "two word sentences", "generalized developmental delay", "born", "high pitched", "cry", "subsequent physical exam revealed microcephaly", "prominent epicanthal folds", "holosystolic murmur best heard", "left 5th intercostal space", "sternum", "abnormality", "following chromosomes", "most likely responsible", "patient's disorder"]}
{"question": "A 62-year old female comes to the physician because of vaginal spotting and urinary urgency for the past 4 days. She has had no fever, abdominal pain, or diarrhea. Menopause occurred at 52 years of age. Her last Pap smear 1 year ago was normal. She has hypertension, hypercholesterolemia, and diabetes. Medications include atorvastatin, hydrochlorothiazide, metformin, and aspirin. She is sexually active with her husband. Her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 12/min, and blood pressure is 155/65 mm Hg. Pelvic exam demonstrates a 4 x 3 cm firm, immobile erythematous mass on the right inner vaginal wall. Which of the following is the most appropriate next step in management?", "answer": "Biopsy of the mass", "options": {"A": "Pap smear", "B": "Biopsy of the mass", "C": "Incision and drainage", "D": "Urine gonorrhea and chlamydia testing"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["62 year old female", "physician", "vaginal spotting", "urinary urgency", "past 4 days", "fever", "abdominal pain", "diarrhea", "Menopause occurred", "years", "age", "last Pap smear 1 year", "normal", "hypertension", "hypercholesterolemia", "diabetes", "Medications include atorvastatin", "hydrochlorothiazide", "metformin", "aspirin", "sexually active", "husband", "temperature", "98", "pulse", "95 min", "respirations", "min", "blood pressure", "65 mm Hg", "Pelvic exam demonstrates", "4", "firm", "immobile erythematous mass", "right inner vaginal", "following", "most appropriate next step", "management"]}
{"question": "A 59-year-old man is evaluated for progressive joint pain. There is swelling and tenderness over the first, second, and third metacarpophalangeal joints of both hands. His hand radiograph is shown. He has had diabetes mellitus for 2 years which is not well controlled with medications. Lab studies show a transferrin saturation of 88% and serum ferritin of 1,200 ng/mL. Which of the following best represents the etiology of this patient condition?", "answer": "Deposition of calcium pyrophosphate (CPP) crystals", "options": {"A": "Deposition of urate crystals", "B": "Deposition of calcium pyrophosphate (CPP) crystals", "C": "Inflammatory rheumatological syndrome", "D": "Pathogenic inoculation of microbes"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old man", "evaluated", "progressive joint pain", "swelling", "tenderness", "first", "second", "third", "joints of", "hands", "hand radiograph", "shown", "diabetes mellitus", "years", "not well controlled with medications", "Lab studies show", "transferrin saturation", "88", "serum ferritin", "1 200 ng mL", "following best represents", "etiology", "patient condition"]}
{"question": "A newborn is found to be extremely cyanotic immediately after birth. He then develops progressive respiratory failure and is admitted to the neonatal ICU. A single loud S2 heart sound is appreciated as well as a machine-like murmur at the left upper sternal border. Radiography shows an enlarged \"egg-shaped\" heart. The newborn is then taken for a atrial septostomy to alleviate the condition pending definitive surgical correction. Which of the following is the most likely cause of this newborn's condition?", "answer": "Transposition of great vessels", "options": {"A": "Coarctation of the aorta", "B": "Persistent truncus arteriosus", "C": "Transposition of great vessels", "D": "Tricuspid atresia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["newborn", "found to", "extremely cyanotic immediately", "birth", "then", "progressive respiratory failure", "admitted", "neonatal ICU", "single loud S2 heart sound", "machine", "murmur", "left upper sternal border", "Radiography shows", "enlarged", "egg shaped", "heart", "newborn", "then taken", "atrial septostomy to", "condition", "definitive surgical correction", "following", "most likely cause", "newborn", "ondition?"]}
{"question": "A 25-year-old male involved in a knife fight presents with a penetrating wound to the chest. The patient is unconscious and cannot provide any further history. Vitals show a temperature of 37-0°C (98.6°F), blood pressure of 85/55 mm Hg, pulse of 115/min, respirations of 19/min, and oxygen saturation of 92% on room air. On physical examination, the patient is diaphoretic and unresponsive. Extremities are pale and cool. There is a 3-inch long penetrating wound between the 3rd and 4th intercostal space on the left side of the chest, which is bleeding profusely. Transthoracic echocardiography reveals a full thickness penetrating injury to the right ventricular free wall. There are no apparent injuries to any coronary arteries or major branches. The patient is intubated and aggressive fluid resuscitation is initiated, including a blood transfusion. Which of the following is the best definitive surgical approach to take in this patient?", "answer": "Interrupted 2-0 polypropylene suture with supporting pledgets", "options": {"A": "Immediate cardiac transplant", "B": "Watchful waiting while resuscitative fluids are initiated", "C": "Interrupted 2-0 polypropylene suture with supporting pledgets", "D": "Needle thoracostomy over the 2nd intercostal space"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old male involved", "knife fight presents", "penetrating wound", "chest", "patient", "unconscious", "provide", "further history", "show", "temperature", "98", "blood pressure", "85 55 mm Hg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "physical examination", "patient", "diaphoretic", "unresponsive", "Extremities", "pale", "cool", "3 inch long penetrating", "3rd", "4th intercostal space", "left side of", "chest", "bleeding", "Transthoracic echocardiography reveals", "full thickness penetrating injury", "right ventricular free wall", "apparent injuries", "coronary", "major branches", "patient", "intubated", "aggressive fluid resuscitation", "initiated", "including", "blood transfusion", "following", "best definitive surgical approach to take", "patient"]}
{"question": "A post-mortem lung examination of a 68-year-old male overweight male with evidence of chronic lower extremity edema, a 60 pack-year smoking history and daily productive cough would be most likely to reveal:", "answer": "Reid Index > 50%", "options": {"A": "Hypereosinophilia", "B": "Reid Index > 50%", "C": "Non-caseating granulomas", "D": "Evidence of a necrotizing infection"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["post-mortem lung examination", "68 year old male overweight", "evidence of chronic lower extremity edema", "60 pack-year smoking history", "daily productive cough", "most likely to reveal"]}
{"question": "A 54-year-old male makes an appointment with his primary care physician due to chronic fatigue that has left him unable to hike or do other physically demanding activities with his friends. He has well-controlled hypertension and diabetes but has otherwise been healthy. He does not smoke but drinks socially with his friends. Physical exam reveals enlarged nodules that are not tender to palpation. A biopsy is obtained showing a characteristic change in chromosome 18. The regulation of which of the following proteins will be most abnormal in this patient?", "answer": "Caspase-9", "options": {"A": "Caspase-9", "B": "CD15", "C": "Cyclin-dependent kinase 4", "D": "Ras pathway transcription factors"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old male makes", "appointment", "primary care physician", "chronic fatigue", "left", "unable to", "physically demanding activities", "friends", "well-controlled hypertension", "diabetes", "healthy", "not smoke", "drinks", "friends", "Physical exam reveals enlarged nodules", "not tender", "palpation", "biopsy", "obtained showing", "characteristic change", "chromosome 18", "regulation", "following proteins", "most abnormal", "patient"]}
{"question": "A 44-year-old African-American woman comes to the physician for a routine examination. She is concerned about cancer because her uncle died of metastatic melanoma 1 year ago. She has no history of serious illness and does not take any medication. She has been working in a law firm for the past 20 years and travels to the Carribean regularly with her husband. Examination of her skin shows no abnormal moles or warts. This woman is at greatest risk of which of the following types of melanoma?", "answer": "Acral lentiginous", "options": {"A": "Desmoplastic", "B": "Nodular", "C": "Acral lentiginous", "D": "Superficial spreading"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old African-American woman", "physician", "routine examination", "concerned", "cancer", "uncle died", "metastatic melanoma", "year", "history", "serious illness", "not take", "medication", "working", "law firm", "past 20 years", "travels", "husband", "Examination of", "skin shows", "abnormal moles", "warts", "woman", "greatest risk", "following types", "melanoma"]}
{"question": "A 60-year-old woman is brought to the clinic by her daughter for evaluation. The daughter reports that her mother has recently been having difficulty combing her hair in the mornings. The patient’s family history is significant for an ischemic stroke in her father. The patient’s past medical history is positive for diverticulosis. She takes no medication. Her blood pressure is 120/70 mm Hg, heart rate is 75/min, respiratory rate is 14/min, and temperature is 37.6°C (99.7°F). On physical examination, the patient’s neck is stiff and she also has bilateral shoulder tenderness; muscle strength is intact. Laboratory work is performed and presented below:\nHemoglobin 12.9 g/dL\nHematocrit 37.7% \nLeukocyte count 5,500/mm3\nNeutrophils 65%\nLymphocytes 30%\nMonocytes 5%\nMean corpuscular volume 82.2 μm3\nPlatelet count 190,000/mm3\nErythrocyte sedimentation rate 65 mm/h\nC-reactive protein 44 mg/dL\nFor which of the symptoms below should the patient be screened?", "answer": "Jaw claudication", "options": {"A": "Jaw claudication", "B": "Heliotrope rash", "C": "Gastroesophageal reflux", "D": "Pink plaques with silvery scales"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["60 year old woman", "brought", "clinic", "daughter", "evaluation", "daughter reports", "mother", "recently", "difficulty combing", "hair", "mornings", "patients family history", "significant", "ischemic stroke", "father", "patients past medical history", "positive", "diverticulosis", "takes", "medication", "blood pressure", "70 mm Hg", "heart rate", "75 min", "respiratory rate", "min", "temperature", "99", "physical examination", "patients neck", "stiff", "bilateral shoulder tenderness", "muscle strength", "intact", "Laboratory work", "performed", "presented", "dL", "count", "mm3", "Mean corpuscular volume", "Platelet count", "rate", "mm/h C-reactive protein", "dL", "symptoms", "patient", "screened"]}
{"question": "A 30-year-old woman comes to the physician because she has been unable to conceive for 3 years. Analysis of her husband's semen has shown normal sperm counts during this time. The patient also reports episodic pelvic and back pain accompanied by painful diarrhea for 5 years. She has about one such episode on average per month for 4–6 days. She has taken ibuprofen for the pain, which has provided some relief. Menses have occurred at regular 29-day intervals since menarche at the age of 14 years and last for 7 days. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic and bimanual examinations are normal; rectal examination is unremarkable. A hysterosalpingogram 6 months prior showed normal results. Which of the following is the most likely underlying mechanism of this patient's symptoms?", "answer": "Endometrial tissue outside the uterine cavity", "options": {"A": "Loss of fallopian tube function following infection", "B": "Smooth muscle tumor arising from the myometrium", "C": "Endometrial tissue outside the uterine cavity", "D": "Increased secretion of androgens and luteinizing hormone"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old woman", "physician", "unable to", "years", "Analysis", "husband's semen", "shown normal sperm counts", "time", "patient", "reports episodic pelvic", "back pain", "painful diarrhea", "5 years", "about one", "episode", "average per month", "days", "taken ibuprofen", "pain", "provided", "relief", "Menses", "occurred", "regular 29 day intervals", "menarche at", "age", "years", "last", "7 days", "sexually active", "husband", "not use contraception", "Vital signs", "normal limits", "Pelvic", "bimanual examinations", "normal", "rectal examination", "unremarkable", "hysterosalpingogram", "months prior showed normal results", "following", "most likely underlying mechanism", "patient's symptoms"]}
{"question": "A 55-year-old truck driver is brought to a physician by his wife. She states that her husband developed a fever and began feeling weak 3 days ago, but has refused medical help. He has been unable to go to work because of his symptoms. The patient has been previously hospitalized for a tricuspid valve replacement surgery 1 year ago and takes aspirin daily. The medical history is also relevant for myocardial infarction 3 years ago and hypertension for the past 10 years, for which he takes lisinopril. His blood pressure is 140/80 mm Hg, the pulse is 82/min, the respirations are 18/minute, and the temperature is 37.2°C (98.9°F). On examination, several hemorrhages are noted on the nail beds of several fingers. Which of the following findings would be most helpful in establishing a diagnosis?", "answer": "Friable irregular masses attached to the valve", "options": {"A": "Bicuspid valve", "B": "Friable irregular masses attached to the valve", "C": "Papillary muscle rupture", "D": "Annular calcification"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["55 year old truck driver", "brought", "physician", "wife", "states", "husband", "fever", "began feeling weak", "days", "refused medical help", "unable to go to work", "symptoms", "patient", "hospitalized", "tricuspid valve replacement surgery 1 year", "takes aspirin daily", "medical history", "relevant", "myocardial infarction", "years", "hypertension", "past 10 years", "takes lisinopril", "blood pressure", "80 mm Hg", "pulse", "min", "respirations", "minute", "temperature", "98 9F", "examination", "several hemorrhages", "noted", "nail beds of", "fingers", "following findings", "most helpful", "establishing", "diagnosis"]}
{"question": "A previously healthy 30-year-old woman comes to the physician for the evaluation of pain during sexual intercourse for 6 months. She also reports frequent episodes of crampy pelvic pain that starts one day before menses and lasts for 7 days. Her symptoms are not relieved with pain medication. Menses occur at regular 28-day intervals and last 5 days. Her last menstrual period was 2 weeks ago. She is sexually active with her husband. She uses a combined oral contraceptive pill. Her vital signs are within normal limits. Physical examination shows rectovaginal tenderness. Cervical and urethral swabs are negative. Transvaginal ultrasonography shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Laparoscopy", "options": {"A": "Measurement of CA-125 levels", "B": "Hysterectomy", "C": "Laparoscopy", "D": "Hysteroscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy 30 year old woman", "physician", "evaluation", "pain", "sexual intercourse", "months", "reports frequent episodes of crampy pelvic pain", "starts one day", "menses", "lasts", "7 days", "symptoms", "not relieved", "pain medication", "Menses occur", "regular", "day intervals", "last 5 days", "last menstrual period", "2 weeks", "sexually active", "husband", "uses", "combined oral contraceptive pill", "vital signs", "normal", "Physical examination shows rectovaginal tenderness", "Cervical", "urethral swabs", "negative", "Transvaginal ultrasonography shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 50-year-old man visits his physician after 20 years of not seeking any medical care. He is concerned about his health after a colleague recently had a heart attack. The patient has no active complaints and says he feels healthy; however, he does not exercise regularly and lives a sedentary lifestyle. He is employed as an administrative position at a local college, and is seated at a desk most of the day. His father had a heart attack at age 54 and his mother is still alive with no health concerns. He does not smoke, only drinks socially, and does not use drugs. Today, his blood pressure is 130/90 mm Hg, pulse is 84/min, and respiratory rate is 14/min. Physical examination reveals an obese male with no significant findings. An ECG shows no abnormalities, and laboratory testing shows the following:\nLaboratory test\nSerum glucose (fasting)  105 mg/dL\nSerum electrolytes \nSodium  142 mEq/L\nPotassium 3.9 mEq/L\nChloride 101 mEq/L\nSerum creatinine 0.8 mg/dl\nBlood urea nitrogen 10 mg/dl\nCholesterol, total 250 mg/dL\nHDL-cholesterol 35 mg/dL\nLDL-cholesterol 186 mg/dL\nTriglycerides 170 mg/dL\nUrinalysis \nGlucose  negative\nKetones negative\nLeucocytes negative\nNitrites negative \nRed blood cells (RBC) negative \nCasts negative \nWhich of the following lab abnormalities in this patient is an indication for treatment?", "answer": "High LDL-cholesterol", "options": {"A": "Blood pressure reading", "B": "Patient’s weight", "C": "High LDL-cholesterol", "D": "Serum glucose level"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["50 year old man visits", "physician", "20 years", "not", "medical care", "concerned", "health", "recently", "heart attack", "patient", "active complaints", "feels healthy", "not exercise", "lives", "sedentary lifestyle", "employed", "administrative position", "local college", "seated", "day", "father", "heart attack", "age 54", "mother", "alive", "health concerns", "not smoke", "only drinks", "not use drugs", "Today", "blood pressure", "90 mm Hg", "pulse", "84 min", "respiratory rate", "min", "Physical examination reveals", "obese male", "significant findings", "ECG shows", "abnormalities", "laboratory testing shows", "following", "Laboratory test Serum glucose", "fasting", "mg", "L Potassium", "creatinine 0.8 mg", "Blood", "nitrogen 10", "Cholesterol", "total", "mg/dL", "cholesterol", "LDL", "Urinalysis", "Ketones", "Leucocytes", "Nitrites", "Red blood cells", "Casts negative", "following lab abnormalities", "patient", "indication", "treatment"]}
{"question": "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?", "answer": "Thoracic aortic rupture", "options": {"A": "Diaphragmatic rupture", "B": "Traumatic bronchial rupture", "C": "Thoracic aortic rupture", "D": "Tension pneumothorax"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department 20 minutes", "involved", "high speed motor vehicle collision", "restrained passenger", "arrival", "lethargic", "incoherent", "severe facial lacerations", "respiratory distress", "pulse", "min", "respirations", "29 min", "blood pressure", "90 58 mm Hg", "Pulse oximetry", "room air shows", "oxygen", "70", "Examination shows multiple facial", "dullness", "percussion", "decreased breath sounds", "left lung base", "Abdominal examination shows diffuse tenderness", "guarding", "Bowel sounds", "normal", "examination shows", "abnormalities", "hemoglobin concentration", "g/dL", "x-ray of", "chest shows", "fractured left second rib", "depression", "left mainstem bronchus", "deviation", "nasogastric tube", "right", "widened mediastinum", "following", "most likely diagnosis"]}
{"question": "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?", "answer": "Propylthiouracil", "options": {"A": "Methimazole", "B": "Propylthiouracil", "C": "Radioiodine therapy", "D": "Thyroidectomy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old", "woman presents", "primary care physicians office", "feelings", "anxiety", "sleep", "finds", "difficult initiating sleep", "occasionally", "palpitations", "feels fatigued", "denies", "similar symptoms", "past", "starting", "new medications", "illicit drugs", "currently 10 weeks pregnant", "followed by", "obstetrician", "temperature", "98", "blood pressure", "70 mmHg", "pulse", "min", "respirations", "min", "physical exam", "patient", "mildly diaphoretic", "skin", "warm", "thyroid gland", "enlarged", "thyroid bruits", "Laboratory studies", "significant", "thyroid-stimulating hormone level", "0.01 U/mL", "normal", "mL", "elevated free thyroxine", "inappropriate", "pregnancy", "following", "best treatment", "patient"]}
{"question": "A 32-year-old woman comes to the physician because of a 3-week history of intermittent loose stools and a 1.2-kg (2.6-lb) weight loss. She immigrated to the US from Uganda 6 weeks ago. Abdominal examination shows diffuse tenderness with no guarding or rebound. The liver is firm and palpable 3 cm below the right costal margin, and the spleen is palpable just below the left costal margin. Her leukocyte count is 12,800/mm3 (12% eosinophils). Stool culture shows several oval-shaped eggs with lateral spines. Microscopic examination of a liver biopsy specimen shows granulomatous inflammation with periportal fibrosis. Exposure to which of the following is most likely to have played a role in the development of this patient's symptoms?", "answer": "Freshwater snails", "options": {"A": "Undercooked pork meat", "B": "Undercooked fish meat", "C": "Dog feces", "D": "Freshwater snails"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "3 week history", "intermittent loose stools", "a", "2 kg", "2.6", "weight loss", "Uganda", "weeks", "Abdominal examination shows diffuse tenderness", "guarding", "liver", "firm", "palpable 3 cm", "right costal margin", "spleen", "palpable", "left costal margin", "leukocyte count", "800 mm3", "eosinophils", "Stool culture shows several oval eggs", "lateral spines", "Microscopic examination of", "liver biopsy specimen shows granulomatous inflammation with", "fibrosis", "Exposure", "following", "most likely to", "played", "role", "development", "patient's symptoms"]}
{"question": "A 3-month-old girl is brought to a pediatrician by her parents. She has central cyanosis without signs of respiratory distress or signs of heart failure. An echocardiogram reveals severe pulmonary outflow obstruction, right ventricular hypertrophy, a ventricular septal defect, and an overriding of the aorta. An elective primary surgical repair is planned at 4 months of age. Which of the following statements is true about this girl’s condition?", "answer": "Normal hemoglobin in patients with tetralogy of Fallot does not rule out iron deficiency anemia.", "options": {"A": "The tricuspid valve is the most common valve affected by bacterial endocarditis in uncorrected tetralogy of Fallot.", "B": "Normal hemoglobin in patients with tetralogy of Fallot does not rule out iron deficiency anemia.", "C": "Cerebral arterial thrombosis is more common than cerebral venous thrombosis.", "D": "Refractory heart failure is a common complication of tetralogy of Fallot."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 month old girl", "brought", "pediatrician", "parents", "central cyanosis", "signs", "respiratory distress", "signs", "heart failure", "echocardiogram reveals severe pulmonary", "obstruction", "right ventricular hypertrophy", "ventricular septal defect", "overriding", "aorta", "elective primary", "planned", "months", "age", "following statements", "true", "girls condition"]}
{"question": "Six days after undergoing surgical repair of a hip fracture, a previously healthy 79-year-old woman is agitated and confused. She is unarousable during the day, but then is awake and impulsive during the night, requiring frequent reorientation. Her husband says that she usually drinks one to two glasses of wine weekly. Her only current medication is oxycodone for pain. Her vital signs are within normal limits. She is distressed and oriented to person but not to place or time. Neurologic examination shows inattentiveness but no focal deficits. Urine dipstick is normal. Which of the following is the most likely cause of her current condition?", "answer": "Delirium", "options": {"A": "Dementia", "B": "Opioid intoxication", "C": "Delirium", "D": "Urinary tract infection"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Six days", "surgical", "hip", "healthy", "year old woman", "agitated", "confused", "day", "then", "awake", "impulsive", "night", "frequent reorientation", "husband", "usually drinks one", "two glasses", "wine weekly", "only current medication", "oxycodone", "pain", "vital signs", "normal limits", "distressed", "oriented to person", "not to place", "time", "Neurologic examination shows inattentiveness", "focal deficits", "Urine dipstick", "normal", "following", "most likely cause", "current condition"]}
{"question": "A 54-year-old woman with a past medical history of mental retardation, hypertension, and diabetes presents to the emergency department with a change in her behavior. Her caretakers state that the patient’s gait suddenly became ataxic, and she became less responsive than her normal non-verbal baseline. Her temperature is 98.5°F (36.9°C), blood pressure is 125/68 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for an unremarkable HEENT exam with normal facial features and no signs of airway compromise. Neurological exam is remarkable for new onset spasticity. The patient has 3+ reflexes and a positive Babinski sign. Musculoskeletal exam is only notable for symmetric swelling and deformities of the patient’s hands bilaterally. Additionally, there is a \"clunk\" when posterior force is applied to the head while anterior force is applied to the cervical spine. Which of the following is the most likely risk factor that predisposed this patient to this condition?", "answer": "Rheumatoid arthritis", "options": {"A": "Cerebral palsy", "B": "Diabetes mellitus", "C": "Down syndrome", "D": "Rheumatoid arthritis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["54 year old woman", "past medical history of mental retardation", "hypertension", "diabetes presents", "emergency department", "change in", "behavior", "caretakers state", "patients gait", "ataxic", "less responsive than", "normal non-verbal baseline", "temperature", "98", "36", "blood pressure", "68 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "unremarkable HEENT exam", "normal facial features", "signs", "airway compromise", "Neurological exam", "new onset spasticity", "patient", "3", "reflexes", "positive Babinski sign", "Musculoskeletal exam", "only notable", "symmetric swelling", "deformities", "patients hands", "posterior force", "applied", "head", "anterior force", "applied", "cervical spine", "following", "most likely risk factor", "predisposed", "patient", "condition"]}
{"question": "A 24-year-old man is brought to the emergency department 15 minutes after he sustained a stab wound to the left chest just below the clavicle. On arrival, he has rapid, shallow breathing and appears anxious. His pulse is 135/min, respirations are 30/min and shallow, and palpable systolic blood pressure is 80 mm Hg. He is intubated and mechanically ventilated. Infusion of 0.9% saline is begun. Five minutes later, his pulse is 133/min and blood pressure is 82/45 mm Hg. Examination shows no active external bleeding. There is a 2.5-cm single stab wound to the left chest at the 4th intercostal space at the midclavicular line. Cardiovascular examination shows muffled heart sounds and jugular venous distention. Breath sounds are normal. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "A drop in systolic blood pressure of 14 mmHg during inspiration", "options": {"A": "Tracheal deviation toward the right side", "B": "Hemoptysis", "C": "A drop in systolic blood pressure of 14 mmHg during inspiration", "D": "Paradoxical motion of part of the chest with breathing\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department 15 minutes", "sustained", "stab wound", "left chest", "clavicle", "arrival", "rapid", "shallow breathing", "appears anxious", "pulse", "min", "respirations", "30/min", "shallow", "palpable systolic blood pressure", "80 mm Hg", "intubated", "ventilated", "Infusion", "0.9", "saline", "begun", "Five minutes later", "pulse", "min", "blood pressure", "mm Hg", "Examination shows", "active external bleeding", "2.5 cm single stab wound", "left chest", "4th intercostal space", "midclavicular line", "Cardiovascular examination shows", "heart sounds", "jugular venous distention", "Breath sounds", "normal", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "A 40-year-old man presents to his primary-care doctor for a follow-up of his hypertension. He is asymptomatic at his office visit and denies any new complaints. He has a 10-year history of hypertension that remains poorly controlled on maximum doses of lisinopril, hydrochlorothiazide, and amlodipine. His past medical history is otherwise unremarkable. He has no smoking history, drinks alcohol occasionally, and denies any illicit drug use. His father required a kidney transplant in his forties. The physical exam is notable for palpable flank masses bilaterally. Laboratory studies show a creatinine of 2.5. The physician orders a renal ultrasound, and the results are shown. Which of the following is the most appropriate test to screen for additional complications of this patient's condition?", "answer": "MR angiography of the brain", "options": {"A": "Colonoscopy", "B": "Esophagogastroduodenoscopy", "C": "Liver function tests", "D": "MR angiography of the brain"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old man presents", "primary-care doctor", "follow-up", "hypertension", "asymptomatic", "office visit", "denies", "new complaints", "a 10 year history of hypertension", "poorly controlled", "maximum doses", "lisinopril", "hydrochlorothiazide", "amlodipine", "past medical history", "unremarkable", "smoking history", "drinks alcohol occasionally", "denies", "illicit drug use", "father required", "kidney transplant", "forties", "physical exam", "notable", "palpable flank masses", "Laboratory studies show", "creatinine", "physician orders", "renal ultrasound", "results", "shown", "following", "most appropriate test to screen", "additional complications", "patient's condition"]}
{"question": "A 17-year-old female is brought to the emergency room by her father because she has been experiencing shortness of breath and chest pain. She says that the chest pain is worse when she breathes or coughs. Furthermore, on the way to the hospital she noticed that there were specks of blood on a tissue that she coughed into. She has no previous medical history and does not recall anything that could have provoked these symptoms. On presentation her temperature is 99°F (37.2°C), blood pressure is 107/65 mmHg, pulse is 102/min, respirations are 21/min, and O2 saturation is 91% on room air. Further testing shows a large filling defect in the pulmonary vessels, and the patient is started on an appropriate treatment intravenously. After drug administration, the effects of the drug are monitored using a standard blood test. Surprisingly, the test results come back within normal parameters. The most likely underlying cause of this patient's symptoms has which of the following modes of inheritance?", "answer": "Autosomal dominant", "options": {"A": "Autosomal dominant", "B": "Autosomal partial dominance", "C": "X-linked dominant", "D": "X-linked recessive"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "brought", "emergency room", "father", "experiencing shortness of breath", "chest pain", "chest pain", "worse", "coughs", "hospital", "blood", "tissue", "coughed", "previous medical history", "not recall", "provoked", "symptoms", "presentation", "temperature", "blood pressure", "65 mmHg", "pulse", "min", "respirations", "min", "O2 saturation", "room air", "Further testing shows", "large filling defect in", "pulmonary", "patient", "started", "appropriate treatment", "drug administration", "effects of", "drug", "monitored using", "standard blood test", "test results", "back", "normal parameters", "most likely underlying cause", "patient's symptoms", "of", "following modes", "inheritance"]}
{"question": "A 26-year-old male presents to his primary care physician with complaints of burning with urination, penile discharge, and intermittent fevers. A urethral smear shows gram negative diplococci within white blood cells. The organism grows well when cultured on Thayer-Martin agar. The patient is prescribed a course of ceftriaxone and the infection resolves without further complication. One year later, the patient returns with the same infection. Which of the following best explains this lack of lasting immunity?", "answer": "Antigenic variation", "options": {"A": "Exotoxin release", "B": "Antigenic variation", "C": "Polysaccharide capsule", "D": "Bruton's agammaglobulinemia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "primary care physician", "complaints", "burning", "urination", "penile discharge", "intermittent fevers", "urethral smear shows gram negative diplococci", "white blood cells", "organism", "well", "cultured", "Thayer-Martin agar", "patient", "prescribed", "course", "ceftriaxone", "infection resolves", "further complication", "One year later", "patient returns", "same infection", "following best", "lack", "immunity"]}
{"question": "A 37-year-old man with no significant past medical history is rear-ended in a motor vehicle accident. He reported significant neck pain to emergency responders, but otherwise denies weakness, numbness or tingling in his extremities. His vitals on presentation to the ED are HR 90, BP 140/80, RR 20, SpO2 98%. What is the most appropriate next step upon presentation to the emergency room?", "answer": "Cervical immobilization", "options": {"A": "Lateral cervical film", "B": "Cervical immobilization", "C": "IV methylprednisolone", "D": "Observation overnight"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "significant past medical history", "rear-ended", "motor vehicle accident", "reported significant neck pain", "emergency responders", "denies weakness", "numbness", "tingling", "extremities", "presentation", "ED", "90", "BP", "80", "RR 20", "98", "most appropriate next step", "presentation", "emergency room"]}
{"question": "A 43-year-old man with a history of schizophrenia, currently controlled with medication, comes in for an appointment with his internist. He is concerned about abnormal discharge from both nipples over the past 3 months. The fluid is white, and he wonders if it could be milk. On further review of systems, he endorses a diminished sexual drive. The physician suspects that one of the patient's medications may be the culprit for these symptoms. Which of the following medications is NOT likely to be the cause?", "answer": "Bromocriptine", "options": {"A": "Haloperidol", "B": "Bromocriptine", "C": "Fluphenazine", "D": "Risperidone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "history of schizophrenia", "currently controlled", "medication", "appointment", "internist", "concerned", "abnormal discharge", "nipples", "past 3 months", "fluid", "white", "milk", "further review of systems", "diminished sexual drive", "physician suspects", "one", "patient's medications", "symptoms", "following medications", "NOT likely to", "cause"]}
{"question": "A 2-day-old male newborn is brought to the physician because of yellowing of the skin and sclerae for 16 hours. He had previously been well. He was born at 38 weeks' gestation via uncomplicated vaginal delivery and weighed 3.1 kg (6 lb 13 oz). The mother has no medical insurance and did not receive prenatal care. The newborn's 4-year-old brother has sickle cell disease. Examination shows jaundice. The abdomen is mildly distended. The liver is palpated 1 cm below the right costal margin and the spleen tip is palpated just below the left costal margin. Laboratory studies show:\nHemoglobin 11 g/dL\nReticulocytes 9%\nLeukocytes 9,100/mm3\nPlatelets 244,000/mm3\nMaternal blood group 0, Rh-negative\nAnti-Rh antibody titer positive\nFetal blood group B, Rh-negative\nSerum\nBilirubin, total 11.3 mg/dL\nDirect 0.3 mg/dL\nWhich of the following is the most likely cause of this patient's condition?\"", "answer": "Anti-B antibodies", "options": {"A": "RBC sickling", "B": "Anti-D antibodies", "C": "Biliary duct malformation", "D": "Anti-B antibodies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["2-day old male newborn", "brought", "physician", "of yellowing", "the skin", "sclerae", "hours", "well", "born", "weeks", "estation ", "ncomplicated  aginal ", ".1  g ", "z)", "other ", "edical insurance ", "ot  eceive  renatal care.", "ewborn'", "ar-o d b other h", "ckle cell disease. ", "amination s ows j undice. ", "domen i", "ldly d stended. ", "ver i", "lpated 1 c  b", "ght c stal margin a", "leen t p i", "lpated j", "ft costal margin. ", "boratory studies s ow: ", "moglobin 1", "d", "ticulocytes 9", "ukocytes 9", "3 P atelets 2", "ternal blood group 0  ", "-n", "tibody t sitive F", "ood group B", "-negative S rum Bilirubin, ", "tal 1", "/dL D rect 0 3 m /dL W", "llowing i", "st l kely c use o", "tient's", "dition?\""]}
{"question": "A 65-year old man presents with gradually worsening rigidity of his arms and legs and slowness in performing tasks. He says he has also noticed hand tremors, which increase at rest and decrease with focused movements. On examination, the patient does not swing his arms while walking and has a shortened, shuffling gait. An antiviral drug is prescribed which alleviates the patient’s symptoms. Which of the following drugs was most likely prescribed to this patient?", "answer": "Amantadine", "options": {"A": "Amantadine", "B": "Ribavirin", "C": "Levodopa", "D": "Zidovudine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old man presents", "worsening rigidity", "arms", "legs", "slowness", "tasks", "hand tremors", "increase", "rest", "decrease", "focused movements", "examination", "patient", "not", "arms", "walking", "shortened", "shuffling gait", "antiviral drug", "prescribed", "patients symptoms", "following drugs", "most likely prescribed", "patient"]}
{"question": "The patient is given prophylactic labetalol and magnesium sulfate. Examination shows absent deep tendon reflexes bilaterally. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Stop magnesium sulfate and give calcium gluconate", "options": {"A": "Stop magnesium sulfate and give calcium gluconate", "B": "Stop labetalol", "C": "Stop magnesium sulfate and give lorazepam", "D": "Perform nerve conduction studies"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["patient", "given prophylactic labetalol", "magnesium sulfate", "Examination shows absent deep tendon reflexes", "following", "most appropriate next step", "management", "patient"]}
{"question": "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:\nCalcium 9.0 mg/dL\nHematocrit (female) 34%\nPotassium 4.0 mEq/L\nSodium 120 mEq/L\nTSH 110.0 µU/mL\nThyroxine (T4) 1.2 µg/dL\nTriiodothyronine (T3) 70 ng/dL\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Myxedema coma", "options": {"A": "Myxedema coma", "B": "Pheochromocytoma crisis", "C": "Septic shock", "D": "Tertiary hyperparathyroidism"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["75 year old woman", "brought", "patrolman", "emergency department", "altered mental status", "found wandering next to", "highway", "patient", "unable to answer questions", "collapsed in transit", "temperature", "4F", "pulse", "40 min", "respirations", "min", "blood pressure", "80 50 mm Hg", "oxygen saturation", "85", "room air", "Physical examination shows", "posturing", "incomprehensible speech", "eyes opening", "pain", "dry hair", "coarse", "waxy skin", "non-pitting edema", "face", "extremities", "Electrocardiogram shows sinus bradycardia", "Laboratory studies show", "Calcium 9 0 mg dL Hematocrit", "female", "Potassium", "0 mEq/L Sodium", "U/mL Thyroxine", "1.2 g/dL Triiodothyronine", "70 ng/dL", "following", "most likely diagnosis", "patient"]}
{"question": "A 66-year-old male presents to his primary care physician to discuss his increasing shortness of breathover the last 3 months. He notes that this is particularly obvious when he is mowing his lawn or climbing the stairs in his home. His past medical history is significant for hypertension that is well-controlled with lisinopril. His vital signs are as follows: T 37.6 C, HR 88, BP 136/58, RR 18, SpO2 97% RA. Physical examination is significant for an early diastolic blowing, decrescendo murmur heard best at the left sternal border, a midsystolic murmur heard best at the right upper sternal border, and a late diastolic rumbling murmur heard best at the apex on auscultation. In addition, an S3 heart sound is also present. Bounding pulses are palpated at the radial arteries bilaterally. Which of the following diagnoses is most likely in this patient?", "answer": "Aortic regurgitation", "options": {"A": "Mitral regurgitation", "B": "Aortic regurgitation", "C": "Aortic stenosis", "D": "Mitral prolapse"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old male presents", "primary care physician to discuss", "increasing shortness", "last", "months", "notes", "climbing", "stairs", "home", "past medical history", "significant", "hypertension", "well-controlled", "lisinopril", "vital signs", "follows", "T", "88", "BP", "58", "RR", "97", "RA", "Physical examination", "significant", "early diastolic blowing", "murmur heard best", "left sternal border", "midsystolic murmur heard best", "right upper sternal border", "late diastolic rumbling murmur heard best", "apex", "auscultation", "addition", "S3 heart sound", "present", "Bounding pulses", "palpated", "radial arteries", "following diagnoses", "most likely", "patient"]}
{"question": "A 28-year-old woman presents following a suicide attempt 2 days ago. She says that her attempt was a result of a fight with her boyfriend and that she slit her wrists in an attempt to keep him from breaking up with her. In the past, she has had many turbulent relationships, both romantic and in her family life. Her family members describe her as being very impulsive and frequently acting to manipulate people’s feelings. Since she was admitted to the hospital, she has spit at several staff members and alternated between sobbing and anger. She has no significant past medical history. The patient denies any history of smoking, alcohol use, or recreational drug use. Which of the following is the most likely diagnosis in this patient?", "answer": "Borderline personality disorder", "options": {"A": "Histrionic personality disorder", "B": "Borderline personality disorder", "C": "Dependent personality disorder", "D": "Narcissistic personality disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents following", "suicide attempt", "days", "attempt", "result", "fight", "boyfriend", "slit", "wrists", "attempt to keep", "breaking", "past", "relationships", "romantic", "family life", "family members", "very impulsive", "frequently acting to manipulate peoples feelings", "admitted", "hospital", "spit", "staff members", "alternated", "sobbing", "anger", "significant past medical history", "patient denies", "history of smoking", "alcohol use", "recreational drug use", "following", "most likely diagnosis", "patient"]}
{"question": "A 50-year-old man presents to his primary care doctor following an inguinal hernia repair. The patient reports no pain in his lower abdomen or groin, no constipation, and states that he enjoys his usual diet. He denies any use of alcohol, tobacco, or illicit drugs. He has returned to work as a cruise ship attendant. Preoperative workup included chest radiography which demonstrated an opacification in his right middle lobe. The patient agrees to undergo computed tomography (CT) of his chest without contrast for further evaluation. The radiologist reports an 8 mm nodule in the patient's peripheral right middle lobe that has regular margins and appears calcified. One year later, the patient obtains another chest CT without contrast that reports the nodule size as 10 mm with similar characteristics. What is the most appropriate next step in management?", "answer": "Positive emission tomography (PET) of chest now", "options": {"A": "CT chest without contrast in 24 months", "B": "Positive emission tomography (PET) of chest now", "C": "Right middle lobectomy now", "D": "Bronchoscopy-guided biopsy now"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["50 year old man presents", "primary care doctor following", "inguinal hernia repair", "patient reports", "pain", "lower abdomen", "groin", "constipation", "states", "usual diet", "denies", "use", "alcohol", "tobacco", "illicit drugs", "returned to work", "ship attendant", "Preoperative workup included chest radiography", "opacification", "right middle lobe", "patient agrees to", "computed tomography", "of", "chest", "contrast", "further evaluation", "radiologist reports", "mm nodule", "patient's peripheral right middle lobe", "regular margins", "appears calcified", "One year later", "patient obtains", "chest CT without contrast", "reports", "nodule size", "10 mm", "similar characteristics", "most appropriate next step", "management"]}
{"question": "A 29-year-old man comes in for evaluation of infertility. He has been trying to conceive for over 2 years with his wife and previous evaluation of his wife's fertility revealed no abnormalities. Physical exam reveals a tall man with long extremities, sparse body hair, gynecomastia, and small testes. Laboratory studies reveal increased serum follicle-stimulating hormone concentration and an increased estradiol:testosterone ratio. Genetic studies reveal a cytogenetic abnormality. If this abnormality was inherited from the patient's father, at which stage of spermatogenesis did this error most likely occur?", "answer": "Primary spermatocyte", "options": {"A": "Primary spermatocyte", "B": "Secondary spermatocyte", "C": "Spermatid", "D": "Spermatozoon"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old man", "evaluation", "infertility", "to", "years", "wife", "previous evaluation", "wife's fertility revealed", "abnormalities", "Physical exam reveals", "tall man", "long extremities", "sparse body hair", "gynecomastia", "small testes", "Laboratory studies reveal increased serum follicle-stimulating hormone concentration", "increased estradiol testosterone ratio", "Genetic studies reveal", "cytogenetic abnormality", "abnormality", "inherited", "patient's father", "stage", "spermatogenesis", "error", "likely occur"]}
{"question": "A 13-year-old boy presents to the emergency department with severe knee, hip, and groin pain. The patient has a past medical history notable only for obesity and asthma. His temperature is 98°F (36.7°C), blood pressure is 124/65 mmHg, pulse is 128/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for an inability of the patient to bear weight on his left leg and limited range of motion of the left hip. Which of the following is the best management for this patient?", "answer": "Surgical pinning of the femoral head", "options": {"A": "Casting and crutches", "B": "Immobilization of the hip in a Pavlik harness", "C": "Supportive therapy and observation", "D": "Surgical pinning of the femoral head"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy presents", "emergency department", "severe knee", "hip", "groin pain", "patient", "past medical history notable only", "obesity", "asthma", "temperature", "36", "blood pressure", "65 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "patient to bear weight", "left leg", "limited range of motion", "left hip", "following", "best management", "patient"]}
{"question": "A 28-year-old man comes to the physician because of diarrhea and crampy abdominal pain for 5 weeks. He has had up to 4 bowel movements per day. Several times he noticed mucoid strings with the stool. He has abdominal bloating. Over the past month, has had a 3.2-kg (7-lb) weight loss. He has not had fever, cough, or bloody stools. He had a painful rash on his lower extremity 3 weeks ago that resolved spontaneously. He works as a pharmacy technician. His temperature is 37.3°C (98.8°F), pulse is 85/min, and blood pressure is 115/77 mm Hg. The abdomen is soft and nontender. His hemoglobin concentration is 11.9 g/dL, MCV is 79 fL, ferritin is 106 ng/dL, and platelet count is 410,000/mm3; serum concentrations of glucose, creatinine, and electrolytes are within the reference range. This patient's condition is most likely associated with which of the following findings?", "answer": "Stool leukocytes", "options": {"A": "Increased serum VIP", "B": "Stool leukocytes", "C": "Melanosis coli", "D": "Normal intestinal mucosa"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "diarrhea", "crampy abdominal pain", "weeks", "up to", "bowel movements", "day", "times", "mucoid strings", "stool", "abdominal bloating", "past month", "3.2 kg", "weight loss", "not", "fever", "cough", "bloody stools", "painful rash", "lower extremity", "weeks", "resolved", "works", "pharmacy technician", "temperature", "3C", "98", "pulse", "85 min", "blood pressure", "mm Hg", "abdomen", "soft", "nontender", "hemoglobin concentration", "g/dL", "MCV", "fL", "ferritin", "ng/dL", "platelet count", "mm3", "serum", "glucose", "creatinine", "electrolytes", "reference range", "patient's condition", "most likely associated with", "following findings"]}
{"question": "A 51-year-old man is brought to the emergency department because of a 2-day history of fever, abdominal pain, and confusion. His wife states that he has been unable to recall his birthday or her name. He was diagnosed with hepatitis C 3 years ago but refused treatment. He has been treated twice in the past year for acute pancreatitis. There is no family history of serious illness. His only medication is a calcium supplement. He emigrated from India 15 years ago. He appears ill. His temperature is 38.3°C (100.9°F), pulse is 101/min, and blood pressure is 104/68 mm Hg. He is confused and oriented only to person. Examination shows scleral icterus and spider angiomas. There are fine tremors of the hands bilaterally. The abdomen is distended and shifting dullness is present. There is diffuse tenderness to palpation with no guarding. Bowel sounds are absent. Laboratory studies show:\nHemoglobin 12.6 g/dL\nLeukocyte count 13,900/mm3\nPlatelet count 342,000/mm3\nSerum\nAlbumin 2.6 g/dL\nTotal bilirubin 2.56 mg/dL\nAlkaline phosphatase 54 U/L\nAST 17 U/L\nALT 44 U/L\nParacentesis is performed. Ascitic fluid analysis shows an albumin concentration of 0.8 g/dL, glucose concentration of 62 mg/dL, and a leukocyte count of 1900/mm3 with 60% neutrophils. Which of the following is the most likely explanation for these findings?\"", "answer": "Bacterial translocation", "options": {"A": "Aseptic peritoneal inflammation", "B": "Neoplastic growth", "C": "Bacterial translocation", "D": "Perforated viscus"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "2-day history", "fever", "abdominal pain", "confusion", "wife states", "unable to recall", "name", "diagnosed", "hepatitis C", "years", "refused treatment", "treated twice", "past year", "acute pancreatitis", "family history", "serious illness", "only medication", "calcium supplement", "India", "years", "appears ill", "temperature", "3C", "100 9F", "pulse", "min", "blood pressure", "68 mm Hg", "confused", "oriented only", "person", "Examination shows scleral icterus", "spider angiomas", "fine tremors of", "hands", "abdomen", "distended", "shifting dullness", "present", "diffuse tenderness", "palpation", "guarding", "Bowel sounds", "absent", "Laboratory studies show", "Hemoglobin 12.6", "Leukocyte", "900 mm3 Platelet count", "Serum", "Total bilirubin", "Alkaline phosphatase 54", "L", "Paracentesis", "performed", "Ascitic shows", "albumin concentration", "0.8 g/dL", "glucose concentration", "62 mg/dL", "leukocyte count", "mm3", "60", "neutrophils", "following", "most likely explanation", "findings"]}
{"question": "An 18-month-old girl is brought to the emergency department because of a cough that her parents are worried about. She has had a runny nose and a low-grade fever for the past 2 days, with some hoarseness and a rough-sounding cough that started this afternoon. This evening she began making some high-pitched sounds when taking breaths, and she seemed to be having some trouble breathing. She is alert and does not appear to be in acute distress. She has a temperature of 38.0°C (100.4 °F), with a respiratory rate of 50/min and O2 saturation of 97%. There is audible inspiratory stridor that worsens when she starts to cry during the examination. She has an occasional barking cough. Her pharynx is mildly erythematous with normal tonsils and no exudate. A frontal X-ray of the upper chest airways is obtained (shown in the image). Which of the following is the best step in management?", "answer": "Racemic epinephrine and intramuscular corticosteroid therapy", "options": {"A": "Anterior-posterior and lateral radiographs of the neck", "B": "Racemic epinephrine and intramuscular corticosteroid therapy", "C": "Intravenous antibiotics", "D": "Trial of bronchodilator therapy and oral steroids"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old girl", "brought", "emergency department", "cough", "parents", "worried about", "runny nose", "low-grade fever", "past 2 days", "hoarseness", "sounding cough", "started", "afternoon", "evening", "began making", "high-pitched sounds", "taking breaths", "to", "trouble breathing", "alert", "not appear to", "acute distress", "temperature", "100", "F", "respiratory rate", "50 min", "O2 saturation", "97", "inspiratory stridor", "worsens", "starts", "cry", "examination", "occasional barking cough", "pharynx", "mildly erythematous", "normal tonsils", "exudate", "frontal X-ray of", "upper chest airways", "obtained", "shown", "image", "following", "best step", "management"]}
{"question": "A 43-year-old woman presents with complaints of retrosternal burning associated with eating. It has persisted for the past several years but has been getting worse. Her past medical history is unknown and this is her first time seeing a doctor. She states she is otherwise healthy and review of systems is notable for episodic hand pain that is worse in the winter as well as a chronic and severe cough with dyspnea which she attributes to her smoking. Her temperature is 97.7°F (36.5°C), blood pressure is 174/104 mmHg, pulse is 80/min, respirations are 22/min, and oxygen saturation is 92% on room air. Physical exam is notable for a young appearing woman with coarse breath sounds. Laboratory studies and urinalysis are ordered and currently pending. Which of the following is the pathophysiology of this patient's chief complaint?", "answer": "Esophageal fibrosis", "options": {"A": "Decreased lower esophageal tone", "B": "Esophageal fibrosis", "C": "Increased lower esophageal tone", "D": "Spastic cricopharyngeal muscle"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "complaints", "retrosternal burning associated with eating", "past", "years", "getting worse", "past medical history", "unknown", "first time seeing", "doctor", "states", "healthy", "review of systems", "notable", "episodic hand", "worse", "winter", "chronic", "severe cough", "dyspnea", "attributes", "smoking", "temperature", "97", "36", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "room air", "Physical exam", "notable", "young appearing woman", "coarse breath sounds", "Laboratory studies", "urinalysis", "ordered", "currently", "following", "pathophysiology", "patient's chief complaint"]}
{"question": "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:\nHemoglobin 8.6 g/dL\nMean corpuscular volume 90 μm3\nReticulocyte count 0.5%\nSerum\nFerritin 325 ng/mL\nUrea nitrogen 45 mg/dL\nCreatinine 2.2 mg/dL\nThe 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?\"", "answer": "JAK/STAT", "options": {"A": "PI3K/Akt/mTOR", "B": "MAP kinase", "C": "JAK/STAT", "D": "IP3"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "chronic kidney disease", "physician", "worsening fatigue", "shortness of breath", "exertion", "months", "year history of poorly controlled type 2 diabetes mellitus", "Current medications include metformin", "insulin", "pulse", "min", "Examination shows conjunctival pallor", "bounding pulses", "Laboratory studies show", "8", "g", "Mean corpuscular volume 90 m3 Reticulocyte count", "5", "Serum", "Urea", "mg", "mg", "patient", "prescribed", "drug to treat", "cause", "current symptoms", "drug", "echanism of action  irectly ", "ollowing  ignaling pathways?"]}
{"question": "A 41-year-old man presents to the emergency department with a 6-hour history of muscle cramping, decreased appetite, and diarrhea. He says that these symptoms came on rapidly but does not recall anything that may have triggered the episode. He has never experienced these symptoms before. His past medical history is significant for obesity, sleep apnea, and type 2 diabetes that is well controlled on metformin. He also has gastroesophageal reflux disease for which he occasionally takes antacids. On presentation he is found to have fast, shallow breathing and abdominal pain that is poorly localized. Basic labs as well as an arterial blood gas are obtained and the results are shown below:\n\nNa+: 139 mEq/L\nCl-: 106 mEq/L\nHCO3-: 11 mEq/L\npH: 7.25\npCO2: 22 mmHg\n\nWhich of the following is the most likely cause of the changes seen in this patient's labs?", "answer": "Metformin", "options": {"A": "Anxiety", "B": "Diarrhea", "C": "Metformin", "D": "Sleep apnea"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "6-hour history", "muscle cramping", "decreased appetite", "diarrhea", "symptoms", "rapidly", "not recall", "triggered", "episode", "never experienced", "symptoms", "past medical history", "significant", "obesity", "sleep apnea", "type 2 diabetes", "well controlled", "metformin", "gastroesophageal reflux disease", "occasionally takes antacids", "presentation", "found to", "fast", "shallow breathing", "abdominal pain", "poorly localized", "Basic labs", "arterial blood gas", "obtained", "results", "shown", "Na", "mEq/L Cl", "mEq/L HCO3", "mEq/L pH", "pCO2", "mmHg", "following", "most likely cause", "changes seen", "patient's labs"]}
{"question": "A scientist is studying the properties of myosin-actin interactions in a sample of human muscle tissue. She has identified a drug that selectively inhibits phosphate release by the myosin head. If she gives this drug to a sample of human muscle tissue under physiologic conditions, which of the following steps in cross-bridge cycling will most likely be blocked?", "answer": "Power stroke", "options": {"A": "Myosin head cocking", "B": "Exposure of myosin-binding sites on actin", "C": "Myosin head binding to actin", "D": "Power stroke"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["scientist", "studying", "properties", "myosin actin interactions", "sample", "human muscle", "identified", "drug", "inhibits phosphate release", "myosin head", "gives", "drug", "sample", "human muscle", "physiologic conditions", "following steps", "cross-bridge cycling", "most likely", "blocked"]}
{"question": "A 16-year-old boy with a seizure disorder and cognitive delay is brought to the physician because of progressively worsening right lower extremity weakness for the past 6 months. He does not make eye contact and sits very close to his mother. Physical examination shows a grade 3/6 holosystolic murmur at the cardiac apex. Neurological examination shows decreased strength in the right lower leg with normal strength in the other extremities. Fundoscopic examination shows several multinodular, calcified lesions in the retina bilaterally. A photograph of his skin findings is shown. This patient's condition is most likely due to a mutation in which of the following?", "answer": "TSC1 gene on chromosome 9", "options": {"A": "NF1 gene on chromosome 17", "B": "NF2 gene on chromosome 22", "C": "TSC1 gene on chromosome 9", "D": "VHL gene on chromosome 3"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "seizure disorder", "cognitive delay", "brought", "physician", "worsening right", "past 6 months", "not make eye contact", "sits very close", "mother", "Physical examination shows", "grade", "6 holosystolic murmur", "cardiac apex", "Neurological examination shows decreased strength", "right lower leg", "normal strength", "extremities", "Fundoscopic examination shows several multinodular", "calcified lesions", "retina", "photograph", "skin findings", "shown", "patient's condition", "most likely due to", "mutation", "following"]}
{"question": "A 66-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. He endorses diffuse abdominal tenderness. His past medical history is notable for diabetic nephropathy, hypertension, dyslipidemia, depression, and morbid obesity. He also is currently being treated for an outbreak of genital herpes. His temperature is 99.0°F (37.2°C), blood pressure is 184/102 mmHg, pulse is 89/min, respirations are 18/min, and oxygen saturation is 98% on room air. Physical exam is notable for an obese man in no acute distress. A CT scan of the abdomen with contrast is performed and is unremarkable. The patient is admitted to the observation unit for monitoring of his pain. Notably, the patient's abdominal pain improves after an enema and multiple bowel movements. The patient's evening laboratory values are ordered and return as seen below.\n\nSerum:\nNa+: 141 mEq/L\nCl-: 99 mEq/L\nK+: 4.8 mEq/L\nHCO3-: 11 mEq/L\nBUN: 20 mg/dL\nGlucose: 177 mg/dL\nCreatinine: 3.1 mg/dL\n\nWhich of the following is the most likely etiology of this patient's laboratory derangements?", "answer": "Metformin", "options": {"A": "Acyclovir", "B": "Atorvastatin", "C": "Metformin", "D": "Metoprolol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["66 year old man presents", "emergency department", "abdominal pain", "nausea", "vomiting", "diffuse abdominal tenderness", "past medical history", "notable", "diabetic nephropathy", "hypertension", "dyslipidemia", "depression", "morbid obesity", "currently", "treated", "outbreak", "genital herpes", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "obese man", "acute distress", "CT scan", "abdomen", "contrast", "performed", "unremarkable", "patient", "admitted", "observation unit", "monitoring", "pain", "patient's abdominal pain improves", "enema", "multiple bowel movements", "patient's evening laboratory values", "ordered", "return", "seen", "Serum", "Na", "mEq/L Cl", "99 mEq/L K", "4.8 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "3.1 mg/dL", "following", "most likely etiology", "patient's laboratory"]}
{"question": "A 56-year-old man comes to the clinic for a check-up. He presents with a 1-year history of worsening shortness of breath and weight loss. He is a former construction worker, and worked in a steel mill when he was in high school. He is an active smoker with a 36-pack-year smoking history. The blood pressure is 130/78 mm Hg, pulse rate is 90/min, respiratory rate is 17/min, and the BMI is 31 kg/m2. The patient is afebrile and the oxygen saturation at rest is 95% on room air. The pulmonary examination reveals a mildly prolonged expiratory phase, and no wheezing or crackles are auscultated. A pulmonary function test is recommended for the patient, and 2 weeks later he returns with a report that shows an FEV1/FVC ratio of 60% and FEV1 of 50% of the predicted value. The lung volumes show a total lung capacity of 110% of predicted value, a residual volume of 115% of predicted value, and a DLCO of 60% of predicted value. Which of the following is the most likely diagnosis?", "answer": "Chronic obstructive pulmonary disease", "options": {"A": "Asbestosis", "B": "Idiopathic pulmonary fibrosis", "C": "Bronchiectasis", "D": "Chronic obstructive pulmonary disease"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "clinic", "check-up", "presents", "year history of worsening shortness", "breath", "weight loss", "former construction worker", "worked", "steel mill", "high school", "active smoker", "36 pack-year smoking history", "blood pressure", "mm Hg", "pulse rate", "90 min", "respiratory rate", "min", "BMI", "31 kg/m2", "patient", "afebrile", "oxygen saturation", "rest", "95", "room air", "pulmonary examination reveals", "mildly prolonged expiratory phase", "wheezing", "crackles", "pulmonary function test", "recommended", "patient", "2 weeks later", "returns", "report", "shows", "FEV1/FVC ratio", "60", "FEV1", "50", "predicted value", "lung volumes show", "total lung capacity", "predicted value", "residual volume", "predicted value", "DLCO", "60", "predicted value", "following", "most likely diagnosis"]}
{"question": "A 25-year-old zookeeper presents to the office complaining of a dry cough, fever, and chills for the past month. He states that the symptoms come in episodes at the end of the workday and last a few hours. He also mentions that he is fatigued all the time. His job includes taking care of various types of birds. He is otherwise fine and denies recent travel or trauma. Medical history is unremarkable and he does not take any medications. He does not smoke cigarettes or drinks alcohol. Allergies include peanuts, dust, and pollen. Childhood asthma runs in the family. Chest X-ray reveals diffuse haziness in both lower lung fields. A PPD skin test is negative. What is the most appropriate treatment for this patient?", "answer": "Avoid exposure to birds", "options": {"A": "Thoracocentesis", "B": "Inhaled beclomethasone", "C": "Avoid exposure to birds", "D": "Isoniazid for 6 months"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old", "presents", "office complaining of", "dry cough", "fever", "chills", "past month", "states", "symptoms", "episodes", "end", "workday", "last", "few hours", "fatigued", "time", "job includes taking care", "various types", "birds", "fine", "denies recent travel", "trauma", "Medical history", "unremarkable", "not take", "medications", "not smoke cigarettes", "drinks alcohol", "Allergies include peanuts", "dust", "pollen", "Childhood runs in", "family", "Chest X-ray reveals diffuse", "lower lung fields", "PPD skin test", "negative", "most appropriate", "patient"]}
{"question": "A 60-year-old female presents to her gynecologist with vaginal bleeding. She underwent menopause ten years prior. She has a past medical history of hypertension and diabetes mellitus. On physical examination, her uterus is uniformly enlarged. Ultrasound reveals a thickened endometrial stripe and tissue biopsy reveals neoplastic endometrial cells. A workup for metastatic disease is negative and the gynecologist recommends a laparoscopic hysterectomy. During the procedure, the surgeon ligates multiple vessels in order to remove the entire uterus. In the immediate postoperative period, the patient develops left-sided flank pain and oliguria. Serum creatinine is found to be 1.4 mg/dl whereas it was 1.0 mg/dl prior to the operation. Renal ultrasound is normal. Urinalysis is notable for hematuria. Ligation of which of the following vessels most likely contributed to this patient’s condition?", "answer": "Uterine artery", "options": {"A": "Artery of Sampson", "B": "Ovarian artery", "C": "Superior vesical artery", "D": "Uterine artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old female presents", "gynecologist", "vaginal bleeding", "menopause ten years prior", "past medical", "diabetes mellitus", "physical examination", "uterus", "enlarged", "Ultrasound reveals", "thickened endometrial stripe", "tissue biopsy reveals neoplastic endometrial cells", "workup", "metastatic disease", "negative", "gynecologist recommends", "laparoscopic hysterectomy", "procedure", "surgeon", "multiple vessels", "order to remove", "entire uterus", "immediate postoperative period", "patient", "left sided flank pain", "oliguria", "Serum creatinine", "found to", "1.4 mg/dl", "1 mg/dl prior to", "operation", "Renal", "normal", "Urinalysis", "notable", "hematuria", "Ligation", "following vessels", "likely contributed", "patients condition"]}
{"question": "A 40-year-old man presents to the physician with progressive weight loss for the last 3 months. He also says he frequently sweats profusely at night and has a recurring low-grade fever, for which he takes acetaminophen. The patient denies any symptoms like cough, breathlessness, or gastrointestinal symptoms. His temperature is 37.1ºC  (98.8ºF), pulse is 76/min, blood pressure is 116/78 mm Hg, and respiratory rate is 13/min. On physical examination, he has generalized pallor. Bilateral cervical lymphadenopathy is present. Examination of his abdomen reveals non-tender hepatosplenomegaly in the right upper quadrant. Laboratory evaluation confirms the diagnosis of Hodgkin’s lymphoma. Which of the following viral infections is most likely to have played a role in the pathogenesis of this patient’s malignancy?", "answer": "Epstein-Barr virus", "options": {"A": "Epstein-Barr virus", "B": "Human T-cell leukemia virus type 1", "C": "Human herpesvirus-8", "D": "Human papillomavirus type 16"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old man presents", "physician", "progressive weight loss", "months", "frequently sweats", "night", "recurring low-grade fever", "takes acetaminophen", "patient denies", "symptoms", "cough", "breathlessness", "gastrointestinal symptoms", "temperature", "98", "pulse", "76 min", "blood pressure", "mm Hg", "respiratory rate", "min", "physical examination", "generalized pallor", "Bilateral cervical", "present", "Examination of", "abdomen reveals non-tender hepatosplenomegaly", "right upper quadrant", "Laboratory evaluation confirms", "diagnosis", "Hodgkins lymphoma", "following viral infections", "most likely to", "played", "role", "pathogenesis", "patients malignancy"]}
{"question": "A 28-year-old gravida 1 at 32 weeks gestation is evaluated for an abnormal ultrasound that showed fetal microcephaly. Early in the 1st trimester, she had fevers and headaches for 1 week. She also experienced myalgias, arthralgias, and a pruritic maculopapular rash. The symptoms resolved without any medications. A week prior to her symptoms, she had traveled to Brazil where she spent most of the evenings hiking. She did not use any mosquito repellents. There is no personal or family history of chronic or congenital diseases. Medications include iron supplementation and a multivitamin. She received all of the recommended childhood vaccinations. She does not drink alcohol or smoke cigarettes. The IgM and IgG titers for toxoplasmosis were negative. Which of the following is the most likely etiologic agent?", "answer": "Zika virus", "options": {"A": "Dengue virus", "B": "Rubella virus", "C": "Toxoplasmosis", "D": "Zika virus"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old gravida 1", "weeks", "evaluated", "abnormal ultrasound", "showed fetal microcephaly", "Early", "1st trimester", "fevers", "headaches", "1 week", "experienced myalgias", "arthralgias", "maculopapular rash", "symptoms resolved", "medications", "week prior to", "symptoms", "traveled", "Brazil", "spent most", "evenings hiking", "not use", "mosquito repellents", "personal", "family history", "chronic", "congenital diseases", "Medications include iron supplementation", "multivitamin", "received", "recommended childhood vaccinations", "not drink alcohol", "smoke cigarettes", "IgM", "titers", "toxoplasmosis", "negative", "following", "most likely etiologic agent"]}
{"question": "A 41-year-old G3P1 woman presents with a sudden onset throbbing headache, tinnitus, nausea, and left-sided weakness. Patient has no significant past medical history and takes no medications.  Her last two pregnancies ended with spontaneous abortions before the 10th week of gestation. No significant family history. Her vital signs include: blood pressure 130/90 mm Hg, pulse 58/min, respiratory rate 11/min, and temperature 36.8℃ (98.2℉). GCS is 14/15. Physical examination shows 3+ deep tendon reflexes and increased muscle tone in the left upper and lower extremities. Laboratory findings are significant for the following:\nPlatelet count 230,000/mm3\nFibrinogen 3.5 g/L\nActivated partial thromboplastin time  70 s\nThrombin time 34 s\n A non-contrast CT of the head is performed and shown in the picture. Which of the following would be the next best diagnostic step in this patient?", "answer": "Mixing study", "options": {"A": "Mixing study", "B": "INR", "C": "Ristocetin-induced platelet aggregation test", "D": "Clot retraction study"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "woman presents", "sudden onset throbbing headache", "tinnitus", "nausea", "left-sided weakness", "Patient", "significant past medical history", "takes", "medications", "last two pregnancies ended", "spontaneous abortions", "week", "gestation", "significant family history", "vital signs include", "blood pressure", "90 mm Hg", "pulse 58 min", "respiratory rate", "min", "temperature 36", "98", "GCS", "Physical examination shows 3", "deep tendon reflexes", "increased muscle tone", "left upper", "lower extremities", "Laboratory findings", "significant", "following", "Platelet", "mm3 Fibrinogen", "g/L Activated partial thromboplastin time", "Thrombin", "contrast CT", "head", "performed", "shown", "picture", "following", "next best diagnostic step", "patient"]}
{"question": "A obstetrician is working in a developing country to help promote maternal health and fetal well being. While there, he delivers a baby who he suspects has congenital hypothyroidism, most likely caused by inadequate maternal iodine intake. Which of the following signs and symptoms would NOT be expected to be observed in this child?", "answer": "Diarrhea", "options": {"A": "Hypotonia", "B": "Diarrhea", "C": "Umbilical hernia", "D": "Macroglossia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["obstetrician", "working", "developing country to help promote maternal health", "fetal well being", "delivers", "baby", "suspects", "congenital hypothyroidism", "most likely caused", "inadequate maternal iodine intake", "following signs", "symptoms", "NOT", "expected to", "observed", "child"]}
{"question": "A 33-year-old nurse is referred to an infectious disease specialist after she exhibited a PPD skin test with 17 mm of induration. She denies any cough, shortness of breath, hemoptysis, weight loss, fatigue, fevers, or night sweats over the last several months. Her temperature is 97.0°F (36.1°C), blood pressure is 120/81 mmHg, pulse is 82/min, respirations are 15/min, and oxygen saturation is 98% on room air. An initial chest radiograph is unremarkable. Which of the following is the most appropriate management of this patient?", "answer": "Isoniazid", "options": {"A": "Isoniazid", "B": "No management indicated", "C": "Repeat PPD in 1 week", "D": "Rifampin, isoniazid, pyrazinamide, and ethambutol"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old nurse", "referred", "infectious disease specialist", "exhibited", "PPD skin test", "mm of induration", "denies", "cough", "shortness of breath", "hemoptysis", "weight loss", "fatigue", "fevers", "night sweats", "months", "temperature", "97", "36", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "initial chest radiograph", "unremarkable", "following", "most appropriate management", "patient"]}
{"question": "An 81-year-old woman is brought to the emergency room by her son after witnessing the patient fall and hit her head. The son reports that the patient was in her usual state of health until she complained of chest palpitations. This startled her while she was climbing down the stairs and lead to a fall. Past medical history is significant for hypertension and atrial fibrillation. Medications are lisinopril, metoprolol, and warfarin. Temperature is 99°F (37.2°C), blood pressure is 152/96 mmHg, pulse is 60/min, respirations are 12/min, and pulse oximetry is 98% on room air. On physical examination, she is disoriented and at times difficult to arouse, the left pupil is 6 mm and non-reactive to light, and the right pupil is 2 mm and reactive to light. A right-sided visual field defect is appreciated on visual field testing. There is 1/5 strength on the right upper and lower extremity; as well as 5/5 strength in the left upper and lower extremity. A computerized tomography (CT) scan of the head is shown. Which of the following most likely explains this patient’s symptoms?", "answer": "Herniation of the uncus", "options": {"A": "Herniation of the uncus", "B": "Herniation of the cingulate gyrus", "C": "Occlusion of the basilar artery", "D": "Occlusion of the anterior spinal artery"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["81 year old woman", "brought", "emergency room", "son", "witnessing", "patient fall", "hit", "head", "son reports", "patient", "usual state of health", "chest palpitations", "climbing", "stairs", "lead", "fall", "Past medical history", "significant", "hypertension", "atrial fibrillation", "Medications", "lisinopril", "metoprolol", "warfarin", "Temperature", "blood pressure", "96 mmHg", "pulse", "60 min", "respirations", "min", "pulse oximetry", "98", "room air", "physical examination", "disoriented", "times difficult", "left pupil", "6 mm", "non reactive to light", "right pupil", "2 mm", "reactive to light", "right-sided visual field defect", "visual field testing", "1/5 strength", "right upper", "lower extremity", "5/5 strength", "left upper", "lower extremity", "computerized tomography", "scan of", "head", "shown", "following most likely", "patients symptoms"]}
{"question": "A 67-year-old man with peripheral neuropathy comes to the physician for a follow-up examination after the results of serum protein electrophoresis showed monoclonal gammopathy. A complete blood count, serum creatinine, and serum electrolyte concentrations are within the reference ranges. A bone marrow biopsy shows 6% monoclonal plasma cells. Further analysis shows that class I major histocompatibility molecules are downregulated in these monoclonal plasma cells. The proliferation of these monoclonal plasma cells is normally prevented by a class of immune cells that lyse abnormal cells without the need for opsonization, priming, or prior activation. Which of the following best describes this class of immune cells?", "answer": "Natural killer cells", "options": {"A": "Bone marrow-derived macrophages", "B": "CD4+ T lymphocytes", "C": "Natural killer cells", "D": "Band neutrophils"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "peripheral neuropathy", "physician", "follow-up examination", "results", "serum protein electrophoresis showed monoclonal gammopathy", "complete blood count", "serum creatinine", "serum electrolyte concentrations", "reference ranges", "bone marrow biopsy shows", "monoclonal plasma cells", "Further analysis shows", "class I major histocompatibility molecules", "monoclonal plasma cells", "proliferation", "monoclonal plasma cells", "prevented", "class", "immune cells", "lyse abnormal cells", "need", "opsonization", "priming", "prior activation", "following best", "class", "immune cells"]}
{"question": "A 47-year-old woman comes to the physician because of progressive muscle weakness for five months. She feels that the muscles in her shoulders and hips have been getting weaker and sometimes feel sore. She now has difficulty getting up from chairs, climbing stairs, and combing her hair. She has also noticed new difficulty with swallowing solid foods, but has no trouble with liquids. She has a 5-year history of hyperlipidemia controlled with fluvastatin. Her maternal uncle died at age 26 from Duchenne's muscular dystrophy and her mother has Hashimoto's thyroiditis. Vital signs are within normal limits. Neurologic examination shows moderate weakness in the arm abductors and hip flexors bilaterally. Deep tendon reflexes are 2+ bilaterally. Laboratory studies show:\nHemoglobin 13.7 g/dL\nLeukocytes 11,200/mm3\nErythrocyte sedimentation rate 33 mm/h\nSerum\nCreatine kinase 212 U/L\nLactate dehydrogenase 164 U/L\nAST 34 U/L\nALT 35 U/L\nWhich of the following is most likely to confirm the diagnosis?\"", "answer": "Intrafascicular infiltration on muscle biopsy", "options": {"A": "Intrafascicular infiltration on muscle biopsy", "B": "Perifascicular and perivascular infiltration on muscle biopsy", "C": "Positive anti-acetylcholine receptor antibodies", "D": "Dystrophin gene mutation on genetic analysis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "of progressive muscle weakness", "five months", "feels", "muscles", "shoulders", "hips", "getting weaker", "sometimes feel sore", "now", "difficulty getting", "chairs", "climbing stairs", "combing", "hair", "new difficulty", "swallowing solid foods", "liquids", "5 year history of hyperlipidemia controlled", "fluvastatin", "maternal uncle died", "age", "Duchenne", "uscular dystrophy ", "other ", "ashimoto'", "yroiditis. ", "tal signs a", "rmal limits. ", "urologic examination s ows m derate w akness i", "m a", "p f exors b", "ep tendon reflexes a", " ", "boratory studies s ow: ", "moglobin 1", "dL L ukocytes 1 0/m 3 E ythrocyte sedimentation rate 3", "S rum C", "Lactate dehydrogenase 1", " U", "llowing i", "st likely t  c nfirm t", "agnosis?\""]}
{"question": "A 41-year-old man presents to the emergency room with sudden onset of blurry vision one hour ago. He states that he was resting at home when he noticed he had difficulty reading. Currently, he is also starting to see double, and is seeing two images on top of each other. Earlier today, he felt ill with nausea, vomiting, and watery diarrhea, which he attributed to food he had eaten at a picnic the day before. When asked which foods he ate, he lists potato salad, a hamburger, deviled eggs, and pickles made by his neighbor. He also heard that his friend who went to the picnic with him has developed similar symptoms and was seen in another hospital earlier. While in the emergency room, the patient’s temperature is 98.4°F (36.9°C), pulse is 75/min, blood pressure is 122/84 mmHg, and respirations are 13/min. Cranial nerve exam is notable for fixed pupillary dilation, and difficulty depressing both eyes. The remainder of his exam is normal. Which of the following is the pathogenesis of this patient’s presentation?", "answer": "Decreased acetylcholine release", "options": {"A": "Decreased acetylcholine release", "B": "Overactivation of adenylate cyclase", "C": "Release of interferon-gamma", "D": "Inhibition of GABA release"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency room", "sudden onset", "blurry vision one hour", "states", "resting at home", "difficulty reading", "Currently", "starting to see double", "seeing two images", "top", "Earlier today", "felt ill", "nausea", "vomiting", "watery diarrhea", "attributed", "food", "eaten", "day", "foods", "ate", "lists potato salad", "deviled eggs", "pickles made", "neighbor", "heard", "friend", "similar symptoms", "seen", "hospital earlier", "emergency room", "patients temperature", "98 4F", "36", "pulse", "75 min", "blood pressure", "84 mmHg", "respirations", "min", "Cranial nerve exam", "notable", "fixed pupillary dilation", "difficulty depressing", "eyes", "exam", "normal", "following", "pathogenesis", "patients presentation"]}
{"question": "A 4-week-old female newborn is brought to the physician because of increasing yellowing of her eyes and skin for 2 weeks. The mother has noticed that the girl's stools have become pale over the past week. She was breastfed since birth but her parents switched her to formula feeds recently after reading on the internet that breastfeeding could be the cause of her current symptoms. The patient was delivered vaginally at 38 weeks' gestation. Pregnancy and delivery were uncomplicated. She appears healthy. Vital signs are within normal limits. She is at the 50th percentile for length and at the 60th percentile for weight. Examination shows scleral icterus and jaundice. The liver is palpated 2 cm below the right costal margin. Cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. Serum studies show:\nBilirubin\nTotal 15 mg/dL\nDirect 12.3 mg/dL\nAlkaline phosphatase 2007 U/L\nAST 53 U/L\nALT 45 U/L\nγ-glutamyl transferase 154 U/L\nBlood group A positive\nWhich of the following is the most likely diagnosis?\"", "answer": "Biliary atresia", "options": {"A": "Galactosemia", "B": "Biliary atresia", "C": "Crigler–Najjar syndrome", "D": "Breast milk jaundice"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["4 week old female newborn", "brought", "physician", "increasing yellowing", "eyes", "skin", "2 weeks", "mother", "girl", "tools ", "ale ", "ast week.", "reastfed ", "irth ", "arents  witched ", "ormula  eeds  ecently ", "eading ", "nternet ", "reastfeeding ", "ause ", "urrent  ymptoms.", "atient ", "elivered ", "eeks'", "station. ", "egnancy a", "livery w", "complicated. ", "pears h althy. ", "tal signs a", "rmal limits. ", "th p rcentile f", "ngth a", "rcentile f", "ight. ", "amination s ows s leral icterus a", "undice. ", "ver i", "lpated 2 c  b", "ght c stal margin. ", "rdiopulmonary e amination s ows n", "normalities. ", "urologic examination s ows n", "cal f ndings. ", "rum s udies s ow: ", "lirubin Total 1", "/dL D rect 1", "/d", "osphatase 2", "L", "utamyl transferase 1", "ood group A", "sitive W", "llowing i", "st likely d agnosis?\""]}
{"question": "A 43-year-old man comes to the emergency department with nausea, abdominal discomfort, diarrhea, and progressive perioral numbness for the past 24 hours. 3 days ago, he underwent a total thyroidectomy for treatment of papillary thyroid cancer. His only medication is a multivitamin supplement. He appears fatigued. While measuring the patient's blood pressure, the nurse observes a spasm in the patient's hand. Physical examination shows a well-healing surgical wound on the neck. Which of the following ECG findings are most likely in this patient?", "answer": "QT prolongation", "options": {"A": "Torsade de pointes", "B": "QT prolongation", "C": "Peaked T waves", "D": "PR prolongation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "nausea", "abdominal discomfort", "diarrhea", "progressive perioral numbness", "past 24 hours", "3 days", "total thyroidectomy", "treatment of papillary thyroid cancer", "only medication", "multivitamin supplement", "appears fatigued", "measuring", "patient's blood pressure", "nurse observes", "spasm", "patient's hand", "Physical examination shows", "well healing surgical", "neck", "following ECG findings", "most likely", "patient"]}
{"question": "A 68-year-old woman presents with left lower quadrant pain that worsens with defecation. She describes the pain as 'crampy'. She also says she has suffered from mild constipation for the past few years. The patient denies any recent weight change or urinary symptoms. Her last menstrual period was 16 years ago. Her body temperature is 37.8°C (100.0°F), pulse is 102/min, respiratory rate is 16/min, and blood pressure is 133/87 mm Hg. On physical examination, tenderness to palpation in the left lower quadrant is present. The laboratory studies are presented as follows:\nHemoglobin 13.2 mg/dL\nHematocrit 48%\nLeukocyte count 16,000/mm³\nNeutrophils 89%\nBands 5%\nEosinophils 0%\nBasophils 0%\nLymphocytes 11%\nMonocytes 0%\nPlatelet count 380,000/mm³\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Diverticulitis", "options": {"A": "Diverticulitis", "B": "Hypothyroidism", "C": "Adenocarcinoma of the colon", "D": "Irritable bowel syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["68 year old woman presents", "left lower quadrant pain", "worsens", "defecation", "pain", "crampy", "suffered", "mild constipation", "past", "years", "patient denies", "recent weight change", "urinary symptoms", "last menstrual period", "years", "body temperature", "100", "pulse", "min", "respiratory rate", "min", "blood pressure", "87 mm Hg", "physical examination", "tenderness", "palpation", "left lower quadrant", "present", "laboratory studies", "presented", "follows", "Hemoglobin", "mg Hematocrit", "Leukocyte 16", "Eosinophils", "Basophils", "Lymphocytes", "Monocytes", "Platelet count", "following", "most likely diagnosis", "patient"]}
{"question": "A 67-year-old man presents to his primary care physician for erectile dysfunction. He states that for the past month he has been unable to engage in sexual intercourse with his wife despite having appropriate sexual desire. He also endorses deep and burning buttock and hip pain when walking, which is relieved by rest. The patient states that he does not have erections at night or in the morning. His past medical history is notable for diabetes, coronary artery disease, and hypertension, and he has a 40 pack-year smoking history. Physical exam is notable for weak lower extremity and femoral pulses. Which of the following is the most specific etiology of this patient’s symptoms?", "answer": "Aortoiliac atherosclerosis", "options": {"A": "Anxiety", "B": "Aortoiliac atherosclerosis", "C": "Spinal stenosis", "D": "Vascular claudication"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["67 year old man presents", "primary care physician", "erectile dysfunction", "states", "past month", "unable", "sexual intercourse", "wife", "appropriate sexual desire", "deep", "burning buttock", "hip pain", "walking", "relieved by rest", "patient states", "not", "erections", "night", "morning", "past medical history", "notable", "diabetes", "coronary artery disease", "hypertension", "40 pack-year smoking history", "Physical exam", "notable", "weak lower extremity", "femoral pulses", "following", "most specific etiology", "patients symptoms"]}
{"question": "A 55-year-old man with a history of chronic glomerulonephritis due to IgA nephropathy presents to your office with bone pain. Which of the following laboratory findings would you most expect upon analysis of this patient's serum?", "answer": "Increased PTH, decreased calcium, increased phosphate, decreased calcitriol", "options": {"A": "Increased PTH, decreased calcium, increased phosphate, decreased calcitriol", "B": "Decreased PTH, increased calcium, increased phosphate, increased calcitriol", "C": "Decreased PTH, decreased calcium, increased phosphate, decreased calcitriol", "D": "Normal PTH, normal calcium, normal phosphate, normal calcitriol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["55 year old man", "history", "chronic glomerulonephritis", "IgA nephropathy presents", "office", "bone pain", "following laboratory findings", "most", "analysis", "patient's serum"]}
{"question": "A medical researcher is studying the physiology of the immune system in order to better understand the effects of HIV on patients. He isolates a group of cells that are shown by flow cytometry to be positive for the cell surface marker CD8. He then mixes this cell population with a group of infected cells, crosslinks extracellular interactions, and immunoprecipitates the CD8 protein. He identifies a protein bound to CD8 that is composed of two chains from an adjacent cell. Which of the following best describes the primary function of the protein that was most likely identified?", "answer": "Binds endogenous peptides that have been transported by the TAP channel", "options": {"A": "Binds complement proteins on the cell surface", "B": "Binds endogenous peptides that are present in the endosome", "C": "Binds endogenous peptides that have been transported by the TAP channel", "D": "Binds exogenous peptides that are present in the endosome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["medical researcher", "studying", "physiology", "immune", "order", "better understand", "effects", "HIV", "patients", "isolates", "group", "cells", "shown", "flow cytometry to", "positive", "cell surface marker CD8", "then mixes", "cell population", "a group", "infected cells", "crosslinks extracellular interactions", "immunoprecipitates", "CD8 protein", "a protein bound", "CD8", "two chains", "adjacent cell", "following best", "primary function", "protein", "most likely identified"]}
{"question": "A 61-year-old Caucasian male presents to your office with chest pain. He states that he is worried about his heart, as his father died at age 62 from a heart attack. He reports that his chest pain worsens with large meals and spicy foods and improves with calcium carbonate. He denies dyspnea on exertion and an ECG is normal. What is the most likely cause of this patient's pain?", "answer": "Gastroesophageal junction incompetence", "options": {"A": "Partially occluded coronary artery", "B": "Umbilical hernia", "C": "Gastroesophageal junction incompetence", "D": "Intestinal metaplasia at the gastroesophageal junction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["61 year old Caucasian male presents", "office", "chest pain", "states", "worried", "heart", "father died", "age 62", "heart attack", "reports", "chest pain worsens", "large meals", "spicy foods", "improves", "calcium carbonate", "denies dyspnea on exertion", "ECG", "normal", "most likely cause", "patient's pain"]}
{"question": "A 36-year-old woman comes to the clinic because of tearing and a foreign body sensation in her eyes bilaterally, which has gradually worsened over the last several weeks. She also notes having occasional palpitations, nervousness, sweating, and heat intolerance. Her past medical history is unremarkable. She reports a 20-pack-year smoking history and is currently a daily smoker. Physical examination shows an anxious, trembling woman. She has eyelid retraction bilaterally, with an inability to fully close her eyes. Her extraocular motility is limited on upgaze. There is no thyromegaly, and no thyroid nodules are noted. Laboratory studies reveal a thyroid-stimulating hormone level of 0.1 μU/mL and total T4 of 42 μg/dL. Thyroid-stimulating immunoglobulin is positive. CT scan of the orbits shows proptosis and marked enlargement of the extraocular muscle with sparing of the tendons. Which of the following would most likely transiently worsen this patient’s eye symptoms?", "answer": "Treatment with radioactive iodine", "options": {"A": "External orbital radiation", "B": "Selenium supplementation", "C": "Systemic corticosteroids", "D": "Treatment with radioactive iodine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old woman", "clinic", "tearing", "foreign body sensation in", "eyes", "worsened", "weeks", "notes", "occasional palpitations", "nervousness", "sweating", "heat intolerance", "past medical history", "unremarkable", "reports", "20 smoking history", "currently", "daily smoker", "Physical examination shows", "anxious", "trembling woman", "eyelid retraction", "close", "eyes", "extraocular motility", "limited", "thyromegaly", "thyroid nodules", "noted", "Laboratory studies reveal", "thyroid-stimulating hormone level", "0.1 U/mL", "total T4", "g/dL", "Thyroid-stimulating immunoglobulin", "positive", "CT scan of", "orbits shows proptosis", "marked enlargement", "extraocular", "tendons", "following", "most likely", "worsen", "patients eye"]}
{"question": "A 7-year-old boy is brought to a pediatrician by his parents for evaluation of frequent bed wetting during the night. A detailed history reveals that there has been no history of urinary incontinence during the day since the boy was 4 years of age, but that he has never been dry at night continuously for 1 week. There is no history of urinary tract infections, urgency, frequency, or hesitancy. On physical examination, the boy’s vital signs are stable. His neurologic and abdominal examinations are completely normal. His laboratory investigations are as follows:\nUrine-specific gravity (first-morning sample) 1.035\nUrine red blood cells Absent\nUrine pus cells Absent\nUrine culture Negative\nWhich of the following is the next step in the management of this patient?", "answer": "Reassuring the parents and use of an enuresis alarm", "options": {"A": "Magnetic resonance imaging (MRI) of the spine", "B": "Reassuring the parents and use of an enuresis alarm", "C": "Treatment with oral oxybutynin", "D": "Treatment with oral imipramine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician", "parents", "evaluation", "frequent bed wetting", "night", "detailed history reveals", "history of urinary incontinence", "day", "boy", "4 years", "age", "never", "dry", "night", "1 week", "history of urinary tract infections", "urgency", "frequency", "hesitancy", "physical examination", "boys vital signs", "stable", "neurologic", "abdominal examinations", "completely normal", "laboratory investigations", "follows", "Urine-specific gravity", "first morning sample", "1", "Urine red blood cells Absent", "Negative", "following", "next step", "management", "patient"]}
{"question": "A 52-year-old man with a history of gastric cancer that was treated with subtotal gastrectomy dies in a motor vehicle collision. At autopsy, examination of the spinal cord shows unilateral atrophy of the neurons in the area indicated by the arrow. Neurological examination of the patient when he was still alive would most likely have shown which of the following findings?", "answer": "Decreased positional sense in the ipsilateral leg", "options": {"A": "Decreased sense of temperature in the ipsilateral arm", "B": "Decreased strength of the contralateral leg", "C": "Decreased vibratory sense in the ipsilateral arm", "D": "Decreased positional sense in the ipsilateral leg"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "history of gastric cancer", "treated with subtotal gastrectomy", "motor vehicle collision", "autopsy", "examination", "spinal cord shows unilateral atrophy", "neurons", "area indicated", "arrow", "Neurological examination of", "patient", "alive", "most likely", "shown", "following findings"]}
{"question": "A 24-year-old pregnant woman at 28 weeks gestation presents to the emergency department with complaints of fever with chills and pain in her knee and ankle joints for the past 2 days. She also complains of headaches and difficulty moving her neck. Further questioning reveals that she had a tick bite on her arm while gardening a few days ago. Past medical history is noncontributory. She takes a multivitamin with iron and folate every day and has been receiving regular prenatal care and the pregnancy is progressing normally. On examination, an erythematous rash is seen on her right arm, as shown in the accompanying photograph. Her obstetric examination is normal. Ultrasound of the fetus is reassuring with a normal heartbeat and no gross abnormalities. A specimen is collected to test for Lyme disease. What is the next best step for this patient?", "answer": "Amoxicilin", "options": {"A": "Ibuprofen", "B": "Tetracycline", "C": "Amoxicilin", "D": "Gentamicin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old pregnant woman", "weeks presents", "emergency department", "complaints", "fever", "chills", "pain in", "knee", "ankle joints", "past 2 days", "headaches", "difficulty moving", "neck", "Further questioning reveals", "tick bite", "arm", "gardening", "few days", "Past medical history", "takes", "multivitamin with iron", "folate", "day", "receiving regular prenatal care", "pregnancy", "progressing", "examination", "erythematous rash", "seen", "right arm", "shown", "photograph", "obstetric examination", "normal", "Ultrasound", "fetus", "reassuring", "normal heartbeat", "gross abnormalities", "specimen", "collected to test", "Lyme disease", "next best step", "patient"]}
{"question": "A 25-year-old woman presents to her physician with a four month history of fatigue and weakness. The weakness has been progressive to the point where she cannot climb stairs and stand from a sitting position. She has only had one menstrual period in the last four months and has never been pregnant. She smokes a pack of cigarettes every day and does not take any medications. Her temperature is 98°F (36.7°C), blood pressure is 160/100 mmHg, pulse is 70/min, and respirations are 15/min. She is obese with a significant pannus. Abdominal striae are present. Her laboratory workup is notable for the following:\n\nSerum:\nNa+: 142 mEq/L\nCl-: 102 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 314 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.1 mg/dL\nAST: 9 U/L\nALT: 8 U/L\n24-hour urinary cortisol: 470 µg (< 300 µg)\nSerum cortisol 30 µg/mL (5-23 µg/dL)\nSerum adrenocorticotropin-releasing hormone (ACTH) 2 pg/mL (> 5 pg/mL)\n\nA 48-hour high dose dexamethasone suppression trial shows that her serum cortisol levels do not decrease. What is the best next step in management?", "answer": "MRI of the adrenal glands", "options": {"A": "MRI of the adrenal glands", "B": "MRI of the chest", "C": "Low dose dexamethasone suppression test", "D": "Inferior petrosal sinus sampling"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "physician", "four month history", "fatigue", "weakness", "weakness", "progressive", "point", "climb stairs", "stand", "sitting position", "only", "one menstrual period", "four months", "never", "pregnant", "smokes", "pack", "cigarettes", "day", "not take", "medications", "temperature", "36", "blood pressure", "100 mmHg", "pulse", "70 min", "respirations", "min", "obese", "significant pannus", "Abdominal striae", "present", "laboratory workup", "notable", "following", "Serum", "Na", "mEq/L Cl", "mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL AST", "U/L ALT", "8 U/L", "hour urinary cortisol", "g", "300 g", "Serum cortisol 30", "mL", "5 23 g/dL", "Serum adrenocorticotropin-releasing hormone", "pg/mL", "5 pg/mL", "48-hour high dose dexamethasone suppression trial shows", "serum cortisol levels", "not decrease", "best next step", "management"]}
{"question": "A 67-year-woman with non-Hodgkin lymphoma comes to the physician because of progressively increasing numbness and tingling in her fingers and toes. Her last cycle of chemotherapy with vincristine was 1 week ago. Physical examination shows decreased sensation to light touch in all distal extremities. Knee and ankle deep tendon reflexes are decreased. Which of the following is the most likely underlying mechanism of this patient’s peripheral neuropathy?", "answer": "Inhibition of beta-tubulin polymerization", "options": {"A": "Inhibition of beta-tubulin polymerization", "B": "Creation of free radicals that unwind DNA", "C": "Inhibition of dihydrofolate reductase", "D": "Incorporation of false pyrimidine analogues into DNA"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year woman", "non-Hodgkin lymphoma", "physician", "increasing numbness", "tingling in", "fingers", "toes", "last cycle", "chemotherapy", "vincristine", "1 week", "Physical examination shows decreased", "light", "distal extremities", "Knee", "ankle deep tendon reflexes", "decreased", "following", "most likely underlying mechanism", "patients peripheral neuropathy"]}
{"question": "A 68-year-old man comes to the physician with a 1-week history of painless hematuria. A CT scan of the urinary tract shows areas of bladder wall thickening. Cystoscopy shows several sessile masses with central necrosis arising from the bladder wall. A biopsy specimen of the bladder masses shows moderately differentiated urothelial cells with abundant mitotic figures and nuclear atypia. The patient most likely has a history of exposure to which of the following?", "answer": "Aromatic amines", "options": {"A": "Ionizing radiation", "B": "Aromatic amines", "C": "Aflatoxins", "D": "Radon"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["68 year old man", "physician", "1-week history of painless hematuria", "CT scan of", "urinary tract shows areas of bladder wall thickening", "Cystoscopy shows several sessile masses", "central necrosis arising", "bladder wall", "biopsy specimen of", "bladder masses shows moderately differentiated urothelial cells", "abundant mitotic figures", "nuclear atypia", "patient", "likely", "history", "exposure", "following"]}
{"question": "A 14-year-old girl comes to the physician with her father for evaluation of her short stature. She feels well overall, but is concerned because all of her friends are taller than her. Her birth weight was normal. Her father reports he had a short stature during his teenage years; he is currently 177 cm (5 ft 10 in) tall. She is at the 2ndpercentile for height and 35th percentile for weight. Breast development is Tanner stage 2. Pubic and axillary hair is absent. An x-ray of the left hand and wrist shows a bone age of 11 years. Which of the following is the most appropriate next best step in management?", "answer": "Reassurance and follow-up", "options": {"A": "Pelvic ultrasound", "B": "Measure serum dehydroepiandrosterone levels", "C": "Reassurance and follow-up", "D": "MRI of the brain"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "father", "evaluation", "short stature", "feels well overall", "concerned", "friends", "birth weight", "normal", "father reports", "short stature", "teenage years", "currently", "5 ft 10", "tall", "height", "percentile", "weight", "Breast development", "Tanner stage 2", "Pubic", "axillary hair", "absent", "x-ray", "left hand", "wrist shows", "bone", "years", "following", "most appropriate next best step", "management"]}
{"question": "A 5-year-old boy is brought to the physician because of facial swelling that started 5 days ago. Two weeks ago, he had a sore throat that resolved spontaneously. His temperature is 37°C (98.6°F), pulse is 107/min, and blood pressure is 94/67 mm Hg. Examination shows pitting edema of the upper and lower extremities as well as periorbital edema. The abdomen is mildly distended. Laboratory studies show:\nHemoglobin 13.1 g/dL\nSerum\nAlbumin 2.1 g/dL\nTotal cholesterol 270 mg/dL\nTriglycerides 175 mg/dL\nUrine\nBlood negative\nGlucose negative\nProtein 4+\nLeukocyte esterase negative\nA renal biopsy of this patient is most likely to show which of the following findings?\"", "answer": "Normal light microscopy findings", "options": {"A": "Mesangial proliferation on light microscopy", "B": "Subepithelial dense deposits on electron microscopy", "C": "Deposits of IgG and C3 at the glomerular basement membrane on immunofluoresence", "D": "Normal light microscopy findings"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["5 year old boy", "brought", "physician", "facial swelling", "started 5 days", "Two weeks", "sore throat", "resolved", "temperature", "98", "pulse", "min", "blood pressure", "67 mm Hg", "Examination shows pitting edema", "upper", "lower extremities", "periorbital edema", "abdomen", "mildly distended", "Laboratory studies show", "Hemoglobin", "Serum", "Triglycerides", "Urine", "negative", "Leukocyte", "renal biopsy", "patient", "most likely to show", "following findings"]}
{"question": "A 60-year-old man is referred to a dermatologist by his family physician for management of a rare case of dermatitis that has not responded to standard therapy with corticosteroids. The patient’s medical history is unremarkable, and he is currently working reduced hours at his job as an accountant. Physical examination reveals confluent scaly patches, plaques, and generalized erythroderma along the torso and lower extremities (see image). There is also a solid skin lesion with a diameter greater than 1 cm. The dermatologist suspects a malignancy and orders a biopsy. Which of the following is the most accurate description of this condition?", "answer": "Tumor arising from cutaneous T cells", "options": {"A": "Vascular tumor containing spindle cells", "B": "Tumor arising from the folliculosebaceous–apocrine germ", "C": "Tumor arising from cutaneous T cells", "D": "Tumor arising from epidermal keratinocytes"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["60 year old man", "referred", "dermatologist", "family physician", "management", "rare case", "dermatitis", "not", "standard therapy", "corticosteroids", "patients medical history", "unremarkable", "currently working reduced hours", "job", "accountant", "Physical examination reveals confluent scaly patches", "plaques", "generalized erythroderma", "torso", "lower extremities", "see image", "solid skin lesion", "diameter greater than", "dermatologist suspects", "malignancy", "orders", "biopsy", "following", "most accurate description", "condition"]}
{"question": "A 35-year-old woman comes to the physician because she has been feeling very stressed over the past several months. During this period, she has found it difficult to relax. She states that her head is full of worries. She works at an accountant's office and reports difficulty in concentrating on her work. She has been working longer shifts because one of her coworkers is on vacation and reports feeling more tired than usual. She is married and frequently fights with her husband. The patient states that in order to deal with her stress, she goes shopping. While shopping, she steals small trivial items and feels immediately relieved thereafter. She discards the objects she steals and has feelings of shame and guilt about her actions. Her husband is concerned about her behavior, but she is unable to stop shoplifting. Her vital signs are within normal limits. On mental status examination, she is oriented to person, place, and time. She reports feeling anxious. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Cognitive behavioral therapy", "options": {"A": "Administration of lithium", "B": "Interpersonal therapy", "C": "Psychodynamic psychotherapy", "D": "Cognitive behavioral therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman", "physician", "feeling very stressed", "past", "months", "period", "found", "difficult", "relax", "states", "head", "full", "worries", "works", "accountant's office", "reports difficulty", "concentrating", "work", "working longer shifts", "one", "coworkers", "vacation", "reports feeling more tired", "usual", "married", "frequently fights", "husband", "patient states", "order to", "stress", "goes shopping", "shopping", "steals small", "items", "feels immediately relieved", "objects", "steals", "feelings", "shame", "guilt", "actions", "husband", "concerned", "behavior", "unable to stop shoplifting", "vital signs", "normal limits", "mental", "oriented to person", "place", "time", "reports feeling anxious", "Physical examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 65-year-old man presents to his primary care physician for a change in his behavior over the past few months. Initially, the patient was noted to be behaving inappropriately including using foul language and grabbing people unexpectedly. This has progressed to a worsening of his memory and trouble caring for himself. His temperature is 98.1°F (36.7°C), blood pressure is 162/103 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for an elderly man who laughs inappropriately at times and who is a poor historian. When he is engaged in conversation, he exhibits word finding difficulty and is rather inattentive. Which of the following is the most likely diagnosis?", "answer": "Frontotemporal dementia", "options": {"A": "Alzheimer dementia", "B": "Frontotemporal dementia", "C": "Kluver-Bucy syndrome", "D": "Vascular dementia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "primary care physician", "change in", "behavior", "past", "months", "Initially", "patient", "noted to", "including using", "language", "grabbing people", "progressed", "worsening", "memory", "caring", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "elderly man", "laughs", "times", "poor historian", "engaged", "conversation", "exhibits word finding difficulty", "rather inattentive", "following", "most likely diagnosis"]}
{"question": "An 11-month-old boy is brought to the clinic by his mother for a rash on his trunk, which he has had for the past 2 days. She notes that he is eating less and is more cranky than usual. His birth history is insignificant, and his immunizations are up to date. Vital signs include: temperature is 37.8°C (100.0°F), pulse is 98/min, and respiratory rate is 16/min. The rash features thin-walled, fluid-filled blisters that rupture easily. Fluid samples from the lesions are sent for analysis to a microbiology lab. The results reveal an infection by the gram-positive bacterium Staphylococcus aureus. The patient is diagnosed with staphylococcal scalded skin syndrome. Which of the following is involved with the primary defense in response to the bacteria and toxins produced by this organism?", "answer": "Immunoglobulin- IgM", "options": {"A": "Immunoglobulin- IgG", "B": "Immunoglobulin- IgD", "C": "Immunoglobulin- IgA", "D": "Immunoglobulin- IgM"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "clinic", "mother", "rash", "trunk", "past 2 days", "notes", "eating less", "more", "usual", "birth history", "immunizations", "date", "Vital signs include", "temperature", "100", "pulse", "98 min", "respiratory rate", "min", "rash features thin walled", "fluid filled blisters", "rupture easily", "Fluid samples", "lesions", "sent", "analysis", "microbiology lab", "results reveal", "infection", "gram-positive bacterium Staphylococcus aureus", "patient", "diagnosed", "staphylococcal scalded skin syndrome", "following", "involved", "primary defense", "response to", "bacteria", "toxins", "organism"]}
{"question": "A 52-year-old man is brought to the emergency department with dry cough, shortness of breath, and low-grade fever that began 6 days ago. He also reports that he has had 3 episodes of watery diarrhea per day for the last 2 days. He appears slightly pale. His temperature is 38.0°C (100.4°F), pulse is 65/min, respirations are 15/min, and blood pressure is 140/78 mm Hg. Diffuse crackles are heard over bibasilar lung fields. Laboratory studies show:\nHemoglobin 13.8 g/dL\nLeukocyte count 16,000/mm3\nPlatelet count 150,000/mm3\nSerum\nNa+ 131 mEq/L\nCl-\n102 mEq/L\nK+ 4.7 mEq/L\nHCO3- 26 mEq/L\nUrea nitrogen 18 mg/dL\nCreatinine 1.2 mg/dL\nAn x-ray of the chest shows patchy infiltrates in both lungs. Which of the following is the most appropriate pharmacotherapy?\"", "answer": "Levofloxacin", "options": {"A": "Levofloxacin", "B": "Trimethoprim/sulfamethoxazole", "C": "Amoxicillin", "D": "Rifampin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "dry cough", "shortness of breath", "low-grade fever", "began 6 days", "reports", "3 episodes of watery diarrhea", "day", "2 days", "appears slightly pale", "temperature", "100 4F", "pulse", "65 min", "respirations", "min", "blood pressure", "mm Hg", "Diffuse crackles", "heard", "lung fields", "Laboratory studies show", "13", "Leukocyte count", "mm3 Platelet count", "4", "HCO3", "mg", "mg", "x-ray of", "chest shows patchy infiltrates", "lungs", "following", "most appropriate pharmacotherapy"]}
{"question": "A transvaginal ultrasound shows an intrauterine heteroechoic mass with numerous anechoic spaces and no identifiable fetus or amniotic fluid. Both the ovaries are enlarged and have multiple thin-walled, septated cysts with clear content. Which of the following is the most likely cause of the ovarian findings?", "answer": "Theca leutein cysts", "options": {"A": "Chocolate cysts", "B": "Corpus luteum cysts", "C": "Yolk sac tumor", "D": "Theca leutein cysts"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["transvaginal ultrasound shows", "intrauterine", "mass", "numerous", "spaces", "identifiable fetus", "amniotic fluid", "ovaries", "enlarged", "multiple thin walled", "septated cysts", "clear content", "following", "most likely cause", "ovarian findings"]}
{"question": "A 75-year-old woman is brought to the emergency department by her son because of a 2-day history of fever, headache, malaise, and dry cough. The patient lives with her son and his family and her son reports that other members of the family have had similar symptoms during the past week but that he has not had any symptoms. The result of a polymerase chain reaction test confirms that the woman is infected with a virus that has a helical capsid and a segmented genome. Which of the following is the most likely explanation for the son being free of symptoms?", "answer": "Serum antibodies against hemagglutinin", "options": {"A": "Serum antibodies against hemagglutinin", "B": "Downregulation of ICAM-1 expression", "C": "Protease-resistant antibodies in nasal secretions", "D": "Homozygous mutation in the CCR5 gene"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["75 year old woman", "brought", "emergency department", "son", "2-day history", "fever", "headache", "malaise", "dry cough", "patient lives with", "son", "family", "son reports", "members", "family", "similar symptoms", "past week", "not", "symptoms", "result", "polymerase chain reaction test confirms", "woman", "infected", "virus", "helical capsid", "segmented genome", "following", "most likely explanation", "son", "free of symptoms"]}
{"question": "A 71-year-old man comes to the physician for a routine visit. His psychiatric history is significant for major depression with psychotic features. He was diagnosed after his wife died from pancreatic cancer four years earlier. Three years ago, he deliberately overdosed on sleeping pills. Today, he feels well but still wakes up frequently at night and cannot sleep through the night. He lives alone in his apartment and has no children. He does not possess a firearm at home but has access to weapons at a local hunting club. The patient currently denies suicidal thoughts or thoughts of self-harm. He takes sertraline and olanzapine. He does not smoke or drink alcohol. Which of the following is the strongest risk factor for suicide in this patient?", "answer": "Previous suicide attempt", "options": {"A": "Previous suicide attempt", "B": "History of psychosis", "C": "Sleeping disorder", "D": "Age\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["71 year old man", "physician", "routine visit", "psychiatric history", "significant", "major depression", "psychotic features", "diagnosed", "wife died", "pancreatic cancer four years earlier", "Three", "overdosed", "sleeping pills", "Today", "feels well", "wakes up frequently", "night", "sleep", "night", "lives alone", "apartment", "children", "not possess", "firearm at home", "access", "weapons", "local hunting club", "patient currently denies suicidal thoughts", "thoughts", "self-harm", "takes sertraline", "olanzapine", "not smoke", "drink alcohol", "following", "strongest risk factor", "suicide", "patient"]}
{"question": "A 4-year-old boy is brought to the physician because of a generalized rash for 3 days. During this period, he has had severe itching and was not able to sleep well. He has also had fever, headache, and some muscle pain. Five days ago, he had a runny nose which subsided with over-the-counter medications. He returned from a camping trip 1 week ago. He attends a daycare center. The patient is at the 55th percentile for height and at the 50th percentile for weight. His temperature is 38.2°C (100.7°F), pulse is 97/min, and blood pressure is 96/60 mm Hg. Examination of the skin shows several macules, papules, and crusted lesions over his face, trunk, and extremities. There are a few fluid-filled vesicles over his abdomen and back. There is no cervical lymphadenopathy. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Chickenpox", "options": {"A": "Measles", "B": "Urushiol-induced dermatitis", "C": "Chickenpox", "D": "Rubella"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "physician", "of", "generalized rash", "3 days", "period", "severe itching", "not able to sleep well", "fever", "headache", "muscle pain", "Five days", "runny nose", "over-the-counter medications", "returned", "camping trip 1 week", "attends", "daycare center", "patient", "percentile", "height", "50th percentile", "weight", "temperature", "100", "pulse", "97 min", "blood pressure", "96 60 mm Hg", "Examination of", "skin shows several macules", "papules", "crusted lesions", "face", "trunk", "extremities", "few fluid filled vesicles", "abdomen", "back", "cervical lymphadenopathy", "examination shows", "abnormalities", "following", "most likely diagnosis"]}
{"question": "A 19-year-old man is brought to the emergency department by ambulance because of unusual behavior that started 3 hours ago while he was at a party. He has a history of major depressive disorder and seasonal allergies. His mother has a history of anxiety. He drinks 5 beers on the weekends. Current medications include amitriptyline and diphenhydramine. The patient does not respond to questions and repeatedly says, \"\"The government is following me everywhere.\"\" His temperature is 37.9°C (100.2°F), pulse is 115/min, respirations are 24/min, and blood pressure is 160/89 mm Hg. He is diaphoretic. He is not oriented to place or time. Neurologic examination shows dilated pupils bilaterally and diffuse hyperreflexia. His feet are cold, and capillary refill time is 3 seconds. After the examination, the patient starts screaming and tries to bite the physician. Urine toxicology screening is positive for ethyl glucuronide. Which of the following is the most likely explanation for this patient's symptoms?\"", "answer": "Synthetic cathinone intoxication", "options": {"A": "Brief psychotic disorder", "B": "Neuroleptic malignant syndrome", "C": "Anticholinergic toxicity", "D": "Synthetic cathinone intoxication"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "ambulance", "unusual behavior", "started 3 hours", "party", "history of major depressive disorder", "seasonal allergies", "mother", "history", "anxiety", "drinks 5 beers", "weekends", "Current medications include amitriptyline", "diphenhydramine", "patient", "not", "questions", "repeatedly", "government", "following", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "diaphoretic", "not oriented to place", "time", "Neurologic examination shows dilated pupils", "diffuse hyperreflexia", "feet", "cold", "capillary refill time", "3 seconds", "examination", "patient starts screaming", "to bite", "physician", "Urine toxicology", "positive", "ethyl glucuronide", "following", "most likely explanation", "patient", "ymptoms?"]}
{"question": "A 22-year-old male presents to the emergency room complaining of neck stiffness. He reports that his neck started “locking” three hours ago. He is now unable to move it. His past medical history is notable for schizophrenia and asthma and he currently takes albuterol as well as another medication whose name he does not remember. His temperature is 99.0°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 105/min, and respirations are 18/min. On physical examination, the patient appears anxious and diaphoretic. He speaks in full sentences and is oriented to person, place, and time. The patient’s neck is flexed and rotated to the right approximately 40 degrees. The right sternocleidomastoid and trapezius are firm and contracted. Extraocular movements are full and intact. Upon further questioning, he reports that he took more medication four hours ago because he was hearing voices. Which of the following should most likely be administered to this patient?", "answer": "Benztropine", "options": {"A": "Glycopyrrolate", "B": "Benztropine", "C": "Levodopa", "D": "Dantrolene"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male presents", "emergency room complaining of neck stiffness", "reports", "neck started locking three hours", "now unable to move", "past medical history", "notable", "schizophrenia", "asthma", "currently takes albuterol", "medication", "name", "not remember", "temperature", "99", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "physical examination", "patient appears anxious", "diaphoretic", "speaks", "full sentences", "oriented to person", "place", "time", "patients neck", "flexed", "rotated", "right approximately 40 degrees", "right sternocleidomastoid", "trapezius", "firm", "contracted", "Extraocular movements", "full", "intact", "further questioning", "reports", "took more medication four hours", "hearing voices", "following", "most likely", "administered", "patient"]}
{"question": "A 13-month-old boy is brought to the physician for a well-child examination. Physical examination shows hepatosplenomegaly. A venous blood sample obtained for routine screening tests is milky. After refrigeration, a creamy supernatant layer appears on top of the sample. Genetic analysis shows a mutation in the apolipoprotein C-II gene (APOC2) on chromosome 19. This patient is at greatest risk for developing which of the following complications?", "answer": "Acute pancreatitis", "options": {"A": "Acute pancreatitis", "B": "Myocardial infarction", "C": "Corneal arci", "D": "Cerebrovascular accident"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old boy", "brought", "physician", "well", "Physical examination shows hepatosplenomegaly", "venous blood sample obtained", "routine screening tests", "milky", "refrigeration", "creamy supernatant layer appears", "top", "sample", "Genetic shows", "mutation", "apolipoprotein C-II gene", "APOC2", "chromosome 19", "patient", "greatest risk", "following complications"]}
{"question": "A 41-year-old man comes to the emergency department with nausea, abdominal discomfort, and diarrhea for the past 2 days. His abdominal discomfort is worse shortly after meals. He has also had progressive perioral numbness and upper-extremity muscle cramping for the past 24 hours. Six months ago, he underwent a Roux-en-Y gastric bypass to treat obesity. He underwent a total thyroidectomy to treat a Hurthle cell lesion 4 days ago. His mother died of lung cancer at age 68. He has smoked 1 pack of cigarettes daily for 22 years. His only current medication is a multivitamin supplement. He appears fatigued. His temperature is 36°C (96.8°F), pulse is 72/min, respirations are 20/min, and blood pressure is 130/70 mm Hg. While measuring the patient's blood pressure, the nurse observes spasm of the patient's hand. Physical examination shows a well-healing surgical wound on the neck. The abdomen is mildly tender to palpation with well-healed laparoscopic incisional sites. The remainder of the examination shows no abnormalities. Serum studies show:\nNa+ 138 mEq/L\nK+ 4.2 mEq/L\nCl- 102 mEq/L\nHCO3- 25 mEq/L\nMg2+ 1.7 mEq/L\nPhosphorus 4.3 mg/dL\n25-hydroxyvitamin D 20 ng/mL (N: 20-100 ng/mL)\nParathyroid hormone 115 pg/mL\nTotal bilirubin, serum 0.7 mg/dL\nAlanine aminotransferase, serum 14 U/L\nAspartate aminotransferase, serum 15 U/L\nAlkaline phosphatase, serum 42 U/L\nWhich of the following is the most appropriate initial step in the management of this patient?\"", "answer": "Administer calcium gluconate", "options": {"A": "Obtain abdominal CT", "B": "Begin rehydration therapy", "C": "Administer calcium gluconate", "D": "Supplementation with vitamin D"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "emergency department", "nausea", "abdominal discomfort", "diarrhea", "past 2 days", "abdominal discomfort", "worse", "meals", "progressive perioral numbness", "upper-extremity muscle cramping", "past 24 hours", "Six months", "Roux-en-Y gastric bypass to treat obesity", "total thyroidectomy to treat", "Hurthle cell lesion", "days", "mother died of lung cancer", "age 68", "smoked 1 pack", "cigarettes daily", "years", "only current medication", "multivitamin supplement", "appears fatigued", "temperature", "96", "pulse", "72 min", "respirations", "20 min", "blood pressure", "70 mm Hg", "measuring", "patient", "lood pressure,", "urse  bserves  pasm ", "atient'", "nd. ", "ysical examination s ows a", "ll-h aling s rgical w", "ck. ", "domen i", "ldly t nder t", "lpation w", "ll-h aled l paroscopic i cisional s", "amination s ows n", "normalities. ", "rum s udies s ow: ", "+ ", "q/L K  ", "2", "O3- ", "7", "osphorus 4", "/d", "2", "/mL (", " ", "-100 n /mL) ", "rathyroid hormone 1", "/mL T tal bilirubin, ", "rum 0 7 m /dL A anine aminotransferase, ", "rum 1", "L A partate aminotransferase, ", "rum 1", "L A kaline phosphatase, ", "rum 4", "L W", "llowing i", "st a propriate i itial s ep i", "nagement o", "tient?\""]}
{"question": "A 9-year-old boy is brought to a physician by his mother for evaluation of generalized weakness, increased urination, and increased thirst. The mother mentions that her boy is always tired, and seems to be getting worse. He prefers watching television rather than going out and playing with other kids. Furthermore, he has had frequent episodes of constipation since birth. Except for frequent cravings for salty foods, the boy eats a regular diet. The patient was delivered healthy and is fully immunized. The medical history is unremarkable, and he takes no medications. He has no siblings. His father is a banker and his mother is a librarian. The pulse is 90/min, the blood pressure is 110/75 mm Hg, and the respiratory rate is 15/min. He is in the bottom 10th percentile for height and weight according to his age. The remainder of the physical examination is unremarkable. He recently had a urinalysis that showed elevated urinary calcium excretion.\nAdditional lab testing results are as follows:\nSerum electrolytes\nSodium 135 mEq/L\nPotassium 3.2 mEq/L\nChloride 95 mEq/L\nPlasma renin activity 10 ng/mL/hr (normal, 0.5–3.3 ng/mL/hr)\nPlasma aldosterone concentration 20 ng/dL (normal, 2–9 ng/dL)\nWhat is the most likely diagnosis?", "answer": "Bartter's syndrome", "options": {"A": "Renal artery stenosis", "B": "Bartter's syndrome", "C": "Pheochromocytoma", "D": "Gitelman's syndrome"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "mother", "evaluation", "generalized weakness", "increased urination", "increased thirst", "mother", "boy", "always tired", "to", "getting worse", "watching television", "out", "playing", "kids", "frequent episodes of constipation", "birth", "Except for frequent cravings", "salty", "boy eats", "regular diet", "patient", "delivered healthy", "medical history", "unremarkable", "takes", "medications", "siblings", "father", "mother", "librarian", "pulse", "90 min", "blood pressure", "75 mm Hg", "respiratory rate", "min", "bottom", "percentile", "height", "weight according", "age", "physical examination", "unremarkable", "recently", "urinalysis", "showed elevated urinary calcium excretion", "Additional lab testing results", "follows", "Serum electrolytes", "mEq/L Potassium", "Chloride 95", "Plasma renin activity 10 ng/mL/hr", "normal", "0", "3 ng/mL/hr", "Plasma aldosterone concentration 20 ng/dL", "normal", "29 ng/dL", "most likely diagnosis"]}
{"question": "A 5-year-old boy of African descent is presented to the emergency department by his parents. The child is clutching his abdomen and crying about pain in his belly. His mother reports intermittent episodes of jaundice with joint and bone pain since he was 5 months old. At presentation, the patient’s vital signs are within normal limits. Physical examination reveals slight jaundice and pale conjunctiva. The spleen is tender and easily palpable. After a complete blood count with differential and an abdominal ultrasound, the patient is found to have sickle-cell disease with splenic infarct. A partial splenectomy is performed. After the operation, the physician provides vaccines against Neisseria meningitidis, Haemophilus influenzae, and Streptococcus pneumoniae. The picture shows a slide obtained from the resected portion of the patient’s spleen. Dysfunction of the zone marked with which number predisposes the patient to the aforementioned infections?", "answer": "1 and 2", "options": {"A": "2 only", "B": "1 only", "C": "1 and 2", "D": "1, 2, and 3"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 year old boy", "African descent", "presented", "emergency department", "parents", "child", "abdomen", "crying", "pain", "belly", "mother reports intermittent episodes of jaundice", "joint", "bone pain", "5 months old", "presentation", "patients vital signs", "normal", "Physical examination reveals slight jaundice", "pale conjunctiva", "spleen", "tender", "easily palpable", "complete blood count", "differential", "abdominal ultrasound", "patient", "found to", "sickle-cell disease", "splenic infarct", "partial splenectomy", "performed", "operation", "physician provides vaccines", "Neisseria meningitidis", "Haemophilus influenzae", "Streptococcus pneumoniae", "picture shows", "slide obtained", "resected portion of", "patients spleen", "Dysfunction", "zone marked", "number", "patient", "infections"]}
{"question": "A 51-year-old woman presents to her primary care physician complaining of months of dry mouth and dry eyes. She says the dryness has become so severe that she has difficulty swallowing food. She has a history of hypertension, for which she takes hydrochlorothiazide (HCTZ), but she has no other medical problems. Family history is significant for her grandmother having systemic lupus erythematosus. The vital signs include: blood pressure 118/76 mm Hg, heart rate 78/min, and respiratory rate 15/min. On physical exam, she has tender parotid glands bilaterally and dries mucous membranes. The presence of serum anti-Ro and anti-La autoantibodies is confirmed at high titers. In addition to her primary diagnosis, which of the following is this patient most at risk for developing in the future?", "answer": "Non-Hodgkin lymphoma", "options": {"A": "Gastric carcinoma", "B": "Non-Hodgkin lymphoma", "C": "Invasive ductal carcinoma of the breast", "D": "Adenocarcinoma of the lung"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "months", "dry mouth", "dry eyes", "dryness", "so severe", "difficulty swallowing food", "history of hypertension", "takes hydrochlorothiazide", "medical problems", "Family history", "significant", "grandmother", "systemic lupus erythematosus", "vital signs include", "blood pressure", "76 mm Hg", "heart rate", "min", "respiratory rate", "min", "physical exam", "tender parotid glands", "dries mucous membranes", "presence", "serum", "Ro", "La autoantibodies", "confirmed", "high titers", "primary diagnosis", "following", "patient most", "risk", "future"]}
{"question": "A 59-year-old man presents to his primary care provider with fatigue, a progressively worsening cough with flecks of blood, shortness of breath, and dark urine. He reports feeling ill for the past 3 weeks. Past medical history is significant for hypertension and hyperlipidemia. He takes chlorthalidone and atorvastatin. Family history is noncontributory. He has smoked 20–30 cigarettes daily for the past 26 years. Anti-glomerular basement membrane serologies are positive. Which of the following is a specific feature for this patient’s condition?", "answer": "Linear IgG staining on immunofluorescence", "options": {"A": "Granulomatous inflammation and necrotizing vasculitis", "B": "Positive cryoglobulins", "C": "Linear IgG staining on immunofluorescence", "D": "Longitudinal splitting and thickening of the glomerular basement membrane"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old man presents", "primary care provider", "fatigue", "worsening cough", "flecks", "blood", "shortness of breath", "dark urine", "reports feeling ill", "past", "weeks", "medical history", "significant", "hypertension", "hyperlipidemia", "takes chlorthalidone", "atorvastatin", "Family history", "smoked", "cigarettes daily", "past", "years", "glomerular basement membrane serologies", "positive", "following", "specific feature", "patients"]}
{"question": "A 32-year-old man with HIV infection is brought to the emergency department by his roommate because of a 2-week history of progressively worsening headache and vomiting. Current medications include trimethoprim-sulfamethoxazole, dolutegravir, and tenofovir-emtricitabine. His temperature is 38.5°C (101.3°F). Physical examination shows nuchal rigidity. Kernig and Brudzinski signs are present. A lumbar puncture is performed and shows an opening pressure of 32 cm H2O (N: < 20). The pathogen isolated from the cerebrospinal fluid (CSF) can be cultured on Sabouraud agar. Further evaluation of this patient's CSF is most likely to show which of the following additional findings?", "answer": "Positive latex agglutination test", "options": {"A": "Positive latex agglutination test", "B": "Positive PCR for HSV-2 DNA", "C": "Presence of tachyzoites", "D": "Increased adenosine deaminase concentration"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "HIV infection", "brought", "emergency department", "roommate", "2-week history", "worsening headache", "vomiting", "Current include trimethoprim-sulfamethoxazole", "dolutegravir", "tenofovir emtricitabine", "temperature", "Physical examination shows nuchal rigidity", "Brudzinski signs", "present", "lumbar puncture", "performed", "shows", "opening pressure", "cm H2O", "N", "20", "pathogen isolated", "cerebrospinal fluid", "cultured", "Sabouraud agar", "Further evaluation of", "patient's CSF", "most likely to show", "following additional findings"]}
{"question": "A 70-year-old woman comes to the physician for the evaluation of back pain. For the past six days, she has had a burning pain in her upper right back and chest. She cannot recall any recent injury and has no prior history of back pain. She has a history of hypertension and gastroesophageal reflux. The patient volunteers at an animal shelter three times a week. She does not smoke or drink alcohol. Current medications include ramipril and pantoprazole. The patient appears healthy and well nourished. Her temperature is 36.9°C (98.42°F), pulse is 76/min, and blood pressure is 145/92 mm Hg. Examination shows a long erythematous rash covered with multiple clear vesicles and crusty lesions extending from her back to below her right breast. Which of the following is the most likely underlying mechanism of the disease?", "answer": "Viral reactivation in dorsal root ganglia", "options": {"A": "Viral reactivation in dorsal root ganglia", "B": "IgA deposits in the upper dermis", "C": "Bacterial lymphatic infection of the epidermis", "D": "Infestation with bloodsucking parasites"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["70 year old woman", "physician", "evaluation of back pain", "past six days", "burning pain", "upper right back", "chest", "recall", "recent injury", "prior history of back pain", "history of hypertension", "gastroesophageal reflux", "patient volunteers", "animal shelter three times", "week", "not smoke", "drink alcohol", "Current medications include ramipril", "pantoprazole", "patient appears healthy", "well nourished", "temperature", "36", "98", "pulse", "76 min", "blood pressure", "mm Hg", "Examination shows", "long erythematous rash covered", "multiple clear vesicles", "crusty lesions extending", "back", "right breast", "following", "most likely underlying mechanism", "disease"]}
{"question": "A type of fatal adrenal cancer has an average survival rate of 3 years after the onset of clinically significant symptoms. It is determined that patients have a 4-year asymptomatic period prior to developing clinical symptoms from this adrenal cancer. A new screening test is developed, and the cancer can now be detected 2 years prior to developing clinical symptoms. A new observational case-control study of screened and unscreened patients measures the median 5-year survival of patients who decline medical and surgical treatment. The screened population has statistically better outcomes. Which step should be undertaken to prevent bias in these conclusions?", "answer": "Using mortality rates in the analysis", "options": {"A": "Using survival rates in the analysis", "B": "Using mortality rates in the analysis", "C": "Increasing the number of screened individuals", "D": "Decreasing the number of screened individuals"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A type", "fatal adrenal cancer", "average survival rate", "years", "onset", "significant symptoms", "patients", "4 year asymptomatic period prior to", "clinical symptoms", "adrenal cancer", "new screening test", "cancer", "now", "detected 2 years prior to", "clinical symptoms", "new observational case-control study", "screened", "patients measures", "median", "year survival", "patients", "medical", "surgical treatment", "screened population", "statistically better outcomes", "step", "to prevent bias", "conclusions"]}
{"question": "A 60-year-old man presents to the office for shortness of breath. The shortness of breath started a year ago and is exacerbated by physical activity. He has been working in the glass manufacturing industry for 20 years. His vital signs include: heart rate 72/min, respiratory rate 30/min, and blood pressure 130/80 mm Hg. On physical exam, there are diminished respiratory sounds on both sides. On the chest radiograph, interstitial fibrosis with reticulonodular infiltrate is found on both sides, and there is also an eggshell calcification of multiple adenopathies. What is the most likely diagnosis?", "answer": "Silicosis", "options": {"A": "Berylliosis", "B": "Silicosis", "C": "Asbestosis", "D": "Talcosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old man presents", "office", "shortness of breath", "shortness of breath started", "year", "exacerbated", "physical activity", "working", "glass manufacturing industry", "20 years", "vital signs include", "heart rate 72 min", "respiratory rate 30/min", "blood pressure", "80 mm Hg", "physical exam", "diminished respiratory sounds", "sides", "chest radiograph", "interstitial", "infiltrate", "found", "sides", "eggshell calcification", "multiple adenopathies", "most likely diagnosis"]}
{"question": "A 43-year-old woman is brought to the emergency department by her brother for severe chest pain. The patient recently lost her husband in a car accident and is still extremely shocked by the event. On physical examination, her blood pressure is 105/67 mm Hg, the heart rate is 96/min and regular, breathing rate is 23/min, and the pulse oximetry is 96%. An S3 heart sound and rales in the lower right and left lung lobes are heard. A 12-lead ECG shows no significant findings. Echocardiography shows an enlarged left ventricle and left atrium. The patient is stabilized and informed about the diagnosis and possible treatment options. Which of the following is the most likely diagnosis?", "answer": "Takotsubo cardiomyopathy", "options": {"A": "Atrial fibrillation", "B": "Constrictive pericarditis", "C": "Takotsubo cardiomyopathy", "D": "Restrictive cardiomyopathy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "brother", "severe chest", "patient recently lost", "husband", "car accident", "extremely shocked", "event", "physical examination", "blood pressure", "67 mm Hg", "heart rate", "96 min", "regular", "breathing rate", "23 min", "pulse oximetry", "96", "S3 heart sound", "rales", "lower right", "left lung lobes", "heard", "12-lead ECG shows", "significant findings", "Echocardiography shows", "enlarged left ventricle", "left atrium", "patient", "stabilized", "informed", "diagnosis", "possible treatment options", "following", "most likely diagnosis"]}
{"question": "A 56-year-old man is brought to the emergency department. He was found unconscious on the street. The staff recognizes him as a local homeless man with a long history of alcoholism. At the hospital, his pulse is 95/min, the blood pressure is 110/70 mm Hg, the respirations are 20/min, and the oxygen saturation is 98% on room air. On physical exam, the unconscious man is covered in bloody vomit with small clots and food particles. He smells of alcohol. A digital exam reveals black tarry stool in the rectal vault. The patient is given oxygen, IV fluids, and an NG-tube is placed and set to intermittent suction. Labs are sent and the patient is prepared for a procedure. Which of the following is the most appropriate next step in his management?", "answer": "Undergo upper GI endoscopy", "options": {"A": "Undergo colonoscopy", "B": "Undergo upper GI endoscopy", "C": "Proton pump inhibitors with anti-H.pylori regimen", "D": "Surgery for peptic ulcer disease"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "found unconscious", "street", "staff", "local homeless man", "long history of alcoholism", "hospital", "pulse", "95 min", "blood pressure", "70 mm Hg", "respirations", "20 min", "oxygen saturation", "98", "room air", "physical exam", "unconscious man", "covered", "bloody vomit", "small clots", "food particles", "smells", "alcohol", "digital exam reveals black tarry stool in", "rectal vault", "patient", "given oxygen", "IV fluids", "NG-tube", "placed", "set", "intermittent suction", "Labs", "sent", "patient", "prepared", "procedure", "following", "most appropriate next step", "management"]}
{"question": "An 8-year-old girl comes to the physician because of a 2-day history of hematuria. Two weeks ago, she had a sore throat that resolved without treatment. Physical examination shows 1+ pitting edema of the lower legs and ankles. Urinalysis shows numerous RBCs and 3+ proteinuria. Her antistreptolysin O titer is elevated. Formation of which of the following is most likely involved in the underlying mechanism of this patient's symptoms?", "answer": "Antigen-antibody complexes", "options": {"A": "Antigen-specific IgE binding to mast cells", "B": "Tissue-specific antibodies", "C": "Antigen-antibody complexes", "D": "Presensitized CD8+ cytotoxic T-cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old girl", "physician", "of", "2-day history", "hematuria", "Two weeks", "sore throat", "resolved", "treatment", "Physical examination shows 1", "pitting edema of", "lower legs", "ankles", "Urinalysis shows numerous RBCs", "3", "proteinuria", "antistreptolysin O titer", "elevated", "Formation", "following", "most likely involved", "underlying mechanism", "patient's symptoms"]}
{"question": "A 25-year-old man presents to the emergency department with altered mental status. He was found down in the middle of the street. His past medical history is unknown. His temperature is 99.0°F (37.2°C), blood pressure is 104/64 mmHg, pulse is 70/min, respirations are 5/min, and oxygen saturation is 91% on room air. The patient is being resuscitated in the trauma bay. Which of the following was most likely to be found on exam?", "answer": "Miosis", "options": {"A": "Ataxia", "B": "Conjunctival injection", "C": "Miosis", "D": "Nystagmus"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "altered mental status", "found", "middle", "street", "past medical history", "unknown", "temperature", "99", "blood pressure", "64 mmHg", "pulse", "70 min", "respirations", "5 min", "oxygen saturation", "room air", "patient", "resuscitated", "trauma bay", "following", "most likely to", "found", "exam"]}
{"question": "A 38-year-old G4P3 presents to her obstetrician’s office for her 20-week anatomy ultrasound. She reports that she feels well and has not experienced any contractions or vaginal bleeding. She also reports good fetal movement. The patient declined prenatal screening earlier in the pregnancy for religious reasons but would now like an anatomy ultrasound to ensure the fetus is growing appropriately. The patient’s previous pregnancies were uncomplicated, and she delivered three healthy babies at full term. On the ultrasound, the technician observes a male fetus with likely intrauterine growth restriction (IUGR). She also notes microcephaly, convex-rounded feet, and clenched fists with overlapping fingers. The technician further notes a medium-sized ventricular septal defect (VSD). The amniotic fluid index (AFI) is 26 cm.\n\nWhich of the following additional findings is most likely to be observed in this fetus?", "answer": "Prominent occiput", "options": {"A": "Cleft palate", "B": "Epicanthal folds", "C": "Micropthlamia", "D": "Prominent occiput"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "presents", "obstetricians office", "20 week anatomy ultrasound", "reports", "feels well", "not experienced", "contractions", "vaginal bleeding", "reports good fetal movement", "patient", "prenatal screening earlier", "pregnancy", "religious reasons", "now", "anatomy ultrasound to ensure", "fetus", "patients previous pregnancies", "uncomplicated", "delivered three healthy babies", "full term", "ultrasound", "technician observes", "male fetus", "likely intrauterine growth restriction", "notes microcephaly", "convex rounded feet", "clenched fists", "overlapping fingers", "technician further notes", "medium sized ventricular septal defect", "amniotic fluid index", "following additional findings", "most likely to", "observed", "fetus"]}
{"question": "An 83-year-old man is admitted to the hospital with fever, weakness, and decreased responsiveness. He is diagnosed with urosepsis based on urinalysis and culture and started on ceftriaxone and intravenous fluids. By hospital day 3, he is clinically improving. During the evening, the patient becomes irritable. He is talking to someone despite nobody being present in the room. He is easily agitated and attempts to strike a nurse with a remote control to his TV. Subsequently, the patient keeps getting out of bed and trying to walk away despite being a fall risk. Which of the following is the most appropriate next step in management?", "answer": "Olanzapine", "options": {"A": "Diphenhydramine", "B": "Lorazepam", "C": "Olanzapine", "D": "Physical restraints"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["83 year old man", "admitted", "hospital", "fever", "weakness", "decreased responsiveness", "diagnosed", "urosepsis based", "urinalysis", "culture", "started", "ceftriaxone", "intravenous fluids", "hospital", "improving", "evening", "patient", "irritable", "talking", "present", "room", "easily agitated", "attempts to strike", "nurse", "remote control", "TV", "patient keeps getting out of bed", "to walk", "fall risk", "following", "most appropriate next step", "management"]}
{"question": "A 26-year-old woman comes to the physician because of fatigue, weight loss, and muscle aches during the past 2 months. There is no personal or family history of serious illness. Her only medication is a multivitamin. A metyrapone stimulation test is performed and the results rule out a diagnosis of adrenal insufficiency. Which of the following changes in laboratory findings are most likely to have been observed in this patient following the administration of the drug?", "answer": "Increase in serum ACTH", "options": {"A": "Increase in serum ACTH", "B": "Decrease in urinary 17-hydroxycorticosteroids", "C": "Decrease in serum 11-deoxycortisol", "D": "Increase in serum cortisol"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "fatigue", "weight loss", "muscle aches", "past", "months", "personal", "family history", "serious illness", "only medication", "multivitamin", "metyrapone stimulation test", "performed", "results rule out", "diagnosis", "adrenal insufficiency", "following changes", "laboratory findings", "most likely to", "observed", "patient following", "administration", "drug"]}
{"question": "An investigator conducts a study to determine whether earlier detection of glioblastoma multiforme (GBM) in patients increases survival time. One subset of study participants consists of asymptomatic individuals who were diagnosed with GBM after undergoing a screening MRI of the brain. The other subset of study participants was diagnosed with GBM only after they developed symptoms. Results from the study show that the asymptomatic patients who were diagnosed with screening MRI had an average survival time that was 6 weeks longer than that of the patients who were diagnosed after symptom onset. Which of the following statistical biases is most likely to have occurred as a result of the endpoint selected for this study?", "answer": "Lead-time bias", "options": {"A": "Observer-expectancy bias", "B": "Length-time bias", "C": "Surveillance bias", "D": "Lead-time bias"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator conducts", "study to", "earlier detection", "glioblastoma multiforme", "patients increases survival time", "One subset", "study participants consists", "asymptomatic individuals", "diagnosed", "GBM", "screening MRI of", "brain", "subset", "study participants", "diagnosed", "GBM only", "symptoms", "Results", "study show", "asymptomatic patients", "diagnosed", "screening MRI", "average survival time", "weeks longer", "patients", "diagnosed", "symptom onset", "following statistical biases", "most likely to", "occurred", "result", "endpoint selected", "study"]}
{"question": "A 23-year-old man is brought to the emergency department 25 minutes after being involved in a high-speed motor vehicle collision in which he was the restrained driver. On questioning by the paramedics, he reported severe chest pain and mild dyspnea. On arrival, he is confused and unable to provide a history. His pulse is 93/min, respirations are 28/min, and blood pressure is 91/65 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. He is able to move his extremities in response to commands. He opens his eyes spontaneously. Pupils are equal and reactive to light. Examination shows multiple bruises over the trunk and extremities. There is a 3-cm (1.2-in) wound at the left fifth intercostal space at the midclavicular line. There is jugular venous distention. Decreased breath sounds and hyperresonance on percussion are noted on the left. Which of the following is the most appropriate next step in management?", "answer": "Needle decompression", "options": {"A": "CT scan of the chest", "B": "Bronchoscopy", "C": "Emergency thoracotomy", "D": "Needle decompression"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old man", "brought", "emergency department", "minutes", "involved", "high speed motor vehicle collision", "restrained driver", "questioning", "paramedics", "reported severe chest", "mild dyspnea", "arrival", "confused", "unable to provide", "history", "pulse", "min", "respirations", "min", "blood pressure", "65 mm Hg", "Pulse oximetry", "room air shows", "oxygen", "88", "able to move", "extremities", "response", "commands", "opens", "eyes", "Pupils", "equal", "reactive to light", "Examination shows multiple bruises", "trunk", "extremities", "3", "1.2", "wound", "left fifth intercostal space", "midclavicular line", "jugular venous distention", "Decreased breath sounds", "hyperresonance", "percussion", "noted", "left", "following", "most appropriate next step", "management"]}
{"question": "A novel type of PET radiotracer is being developed to evaluate patients with Parkinson’s disease. A clinical research study has enrolled 1,200 patients, half of whom have the disease. The scan is found to be positive in 590 of the 600 patients with known PD, and positive in 20 of the 600 patients without PD. What is the test’s overall specificity?", "answer": "580 / (580 + 20)", "options": {"A": "580 / (20 + 590)", "B": "580 / (10 + 580)", "C": "590 / (590 + 10)", "D": "580 / (580 + 20)"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["A novel type", "PET radiotracer", "to evaluate patients", "Parkinsons disease", "clinical", "enrolled 1 200 patients", "half", "disease", "scan", "found to", "positive", "600 patients", "known PD", "positive", "20", "600 patients", "PD", "tests overall specificity"]}
{"question": "A 55-year-old man presents to a rheumatologist with bilateral wrist and knee pain that has been present for the last 10 years. The patient was a professional athlete who retired at age 50. He also notes morning stiffness in his joints that lasts approx. 50 minutes. He denies joint swelling, color changes in his digits, dryness of mucous membranes, and constitutional symptoms such as fever and chills. On physical exam, the physician notes several non-tender nodules on the left 1st, 3rd, and 4th distal interphalangeal joints. There is also tenderness with palpation at the base of both thumbs. The patient’s knees are enlarged, bilaterally, and he has pain and crepitus on passive range of motion. Which of the following is the most likely diagnosis?", "answer": "Osteoarthritis", "options": {"A": "Ankylosing spondylitis", "B": "Gout", "C": "Osteoarthritis", "D": "Fibromyalgia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["55 year old man presents", "rheumatologist", "bilateral wrist", "knee pain", "present", "10 years", "patient", "professional athlete", "retired", "age 50", "notes morning stiffness", "joints", "lasts", "50 minutes", "denies joint swelling", "color changes", "digits", "dryness", "mucous membranes", "constitutional", "fever", "chills", "physical exam", "physician notes several non-tender nodules", "left 1st", "3rd", "4th distal interphalangeal joints", "tenderness", "palpation", "base", "thumbs", "patients knees", "enlarged", "pain", "crepitus", "passive range of motion", "following", "most likely diagnosis"]}
{"question": "A 40-year-old businessman who was previously well is brought into the emergency department by his assistant with a complaint of left-sided weakness after a chiropractic neck manipulation. He has never felt like this before. Past medical history is insignificant. His blood pressure is 125/75 mm Hg, pulse 86/min, respiratory rate 13/min, temperature 36.8°C (98.2°F). A T2-weighted MRI shows a left C5 hemicord lesion. The patient is treated with cervical immobilization, a course of steroids, and physical therapy. What other finding will most likely be seen in this patient?", "answer": "Right-sided analgesia", "options": {"A": "Spastic paralysis at the level of lesion", "B": "Right-sided Horner's syndrome", "C": "Contralateral corticospinal tract involvement", "D": "Right-sided analgesia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["40 year old", "well", "brought", "emergency department", "assistant", "complaint", "left-sided weakness", "chiropractic neck", "never felt", "before", "Past medical history", "blood pressure", "75 mm Hg", "pulse", "min", "respiratory rate", "min", "temperature 36", "98", "T2 weighted MRI shows", "left", "lesion", "patient", "treated with cervical immobilization", "course", "steroids", "physical therapy", "finding", "most likely", "seen", "patient"]}
{"question": "A previously healthy 19-year-old man comes to the physician with right-sided, dull, throbbing scrotal pain for 12 hours. He has also had a burning sensation on urination and increased urinary frequency for the past 3 days. He has not had urethral discharge. He is sexually active with one female partner and does not use condoms. Vital signs are within normal limits. Physical examination shows a tender right testicle; lifting it provides relief. The penis appears normal, with no discharge at the meatus. Laboratory studies show a normal complete blood count; urinalysis shows 3 WBC/hpf. A Gram stain of a urethral swab shows polymorphonuclear leukocytes but no organisms. Testicular ultrasound shows increased blood flow to the right testicle compared to the left. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Chlamydia trachomatis infection", "options": {"A": "Neisseria gonorrhoeae infection", "B": "Testicular tumor", "C": "Chlamydia trachomatis infection", "D": "Varicocele"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "right-sided", "dull", "throbbing scrotal pain", "12 hours", "burning sensation", "urination", "increased urinary frequency", "past 3 days", "not", "urethral discharge", "sexually active", "one female partner", "not use condoms", "Vital signs", "normal", "Physical examination shows", "tender right testicle", "lifting", "provides relief", "penis appears normal", "discharge", "meatus", "Laboratory studies show", "normal complete blood count", "urinalysis shows 3 WBC/hpf", "Gram stain", "urethral swab shows polymorphonuclear leukocytes", "organisms", "Testicular ultrasound shows increased blood flow", "right testicle compared", "left", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 4-month-old infant is brought to the office by his parents due to sudden nose bleeding without trauma of any kind. He has a 1-month history of multiple bruising that measures 1 cm in diameter each in the hands and feet, and tiny red spots that appeared in the upper and lower extremities without any trauma either. He has no prior bleeding history nor any relevant family history. The vital signs include: heart rate 190/min, respiratory rate 40/min, blood pressure 99/42 mm Hg, and temperature 36.6 °C (97.9 °F). His physical exam shows pale skin color, petechiae in the soft palate and in the upper and lower extremities as well as ecchymosis in the back of the hands and feet.\nThe complete blood count results are as follows:\nHemoglobin 8.9 g/dL\nHematocrit 41%\nLeukocyte count 10,500/mm3\nNeutrophils 53%\nBands 2%\nEosinophils 1%\nBasophils 0%\nLymphocytes 33%\nMonocytes 2%\nPlatelet count 450,000/mm3\nThe coagulation test results are as follows:\nPartial thromboplastin time (activated) 30.0 sec\nProthrombin time 13.6 sec\nInternational normalized ratio 0.99\nFibrinogen 364.9 mg/dL\nThe blood smear shows hypochromia, poikilocytosis, and large platelets, while a platelet aggregation test with ristocetin is normal. The overall bleeding time is increased. What is the most likely cause of this patient’s condition?", "answer": "Glanzmann’s thrombasthenia", "options": {"A": "Von Willebrand disease", "B": "Glanzmann’s thrombasthenia", "C": "Bernard-Soulier disease", "D": "Scurvy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 month old infant", "brought", "office", "parents due to sudden nose bleeding", "trauma", "kind", "month history", "multiple bruising", "measures", "diameter", "hands", "feet", "red spots", "appeared", "upper", "lower extremities", "trauma", "prior bleeding history", "relevant family history", "vital signs include", "heart rate", "min", "respiratory rate 40 min", "blood pressure 99", "mm Hg", "temperature 36", "97", "F", "physical exam shows pale", "petechiae", "soft palate", "upper", "lower extremities", "ecchymosis", "back of", "hands", "feet", "complete blood count results", "follows", "Hemoglobin", "g/dL Hematocrit", "count", "500 mm3", "Bands", "Eosinophils", "Basophils", "Lymphocytes", "Platelet count", "coagulation test results", "follows", "Partial thromboplastin time", "activated", "0", "Prothrombin time 13.6", "ratio", "99 Fibrinogen 364 9 mg/dL", "blood smear shows hypochromia", "poikilocytosis", "large platelets", "platelet aggregation test with ristocetin", "normal", "overall bleeding time", "increased", "most likely cause", "patients condition"]}
{"question": "A 6-year-old boy is brought to the physician by his mother because of a 2-day history of dysuria and increased urinary frequency. Vital signs are within normal limits. Urinalysis shows cloudy, red urine. This patient's clinical presentation is best explained by an infection with a virus with which of the following features?", "answer": "Non-enveloped with linear, double-stranded DNA", "options": {"A": "Non-enveloped with linear, single-stranded DNA", "B": "Non-enveloped with linear, single-stranded RNA", "C": "Enveloped with linear, single-stranded RNA", "D": "Non-enveloped with linear, double-stranded DNA"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "mother", "2-day history", "dysuria", "increased urinary frequency", "Vital signs", "normal", "Urinalysis shows cloudy", "red", "patient's clinical presentation", "best", "infection", "virus", "following features"]}
{"question": "A 13-year-old boy is brought to his pediatrician due to a left breast lump under his nipple. He noticed it last month and felt that it has increased slightly in size. It is tender to touch but has no overlying skin changes. There is no breast discharge. The patient has cryptorchidism as an infant and underwent a successful orchiopexy. In addition, he was recently diagnosed with ADHD and is currently on methylphenidate with improvement in his symptoms. He has a family history of type I diabetes in his father and breast fibroadenoma in his mother. On exam, the patient is at the 82nd percentile for height, 79th percentile for weight, and 80th percentile for BMI. He has tanner IV pubic hair. Testicular volume is 7 mL on each side, and both testes are smooth and freely mobile. Breast exam shows a normal right breast and a 3-centimeter round, firm, and slightly tender discrete mass under the left nipple. Which of the following is the most likely etiology of this patient’s condition?", "answer": "Glandular tissue enlargement", "options": {"A": "Klinefelter syndrome", "B": "Glandular tissue enlargement", "C": "Lipomastia (pseudogynecomastia)", "D": "Testicular cancer"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "pediatrician due to", "left breast lump", "nipple", "last month", "felt", "increased slightly", "size", "tender", "touch", "skin changes", "breast discharge", "patient", "cryptorchidism", "infant", "successful orchiopexy", "addition", "recently diagnosed", "ADHD", "currently", "methylphenidate", "improvement", "symptoms", "family history", "type I", "father", "breast fibroadenoma", "mother", "exam", "patient", "percentile", "height", "percentile", "weight", "80th percentile", "BMI", "tanner IV pubic hair", "Testicular volume", "7 mL", "side", "testes", "smooth", "freely mobile", "Breast exam shows", "normal right", "3 centimeter round", "firm", "slightly tender discrete mass", "left", "following", "most likely etiology", "patients condition"]}
{"question": "A 35-year-old Caucasian female presents to the emergency room with unilateral leg swelling. She reports that she developed painful left-sided leg swelling and redness earlier in the day. She is otherwise healthy and takes no medications. She denies any recent prolonged travel. She experienced a similar episode affecting the opposite leg one year ago and was diagnosed with a thrombus in the right femoral vein. On examination, the left leg is erythematous and swollen. Passive dorsiflexion of the left ankle elicits pain in the left calf. Ultrasound of the leg reveals a thrombus in the left popliteal vein. A genetic workup reveals that she has an inherited condition. What is the most likely pathophysiology of this patient’s condition?", "answer": "Resistance to clotting factor degradation", "options": {"A": "Elevated serum homocysteine", "B": "Thrombin inhibitor deficiency", "C": "Auto-antibodies directed against phospholipids", "D": "Resistance to clotting factor degradation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old Caucasian female presents", "emergency room", "unilateral leg swelling", "reports", "painful left-sided leg swelling", "redness earlier", "day", "healthy", "takes", "medications", "denies", "recent prolonged travel", "experienced", "similar episode affecting", "opposite leg one year ago", "diagnosed", "thrombus", "right femoral vein", "examination", "left leg", "erythematous", "swollen", "Passive dorsiflexion of", "left ankle elicits pain", "left calf", "Ultrasound of", "leg reveals", "thrombus", "left popliteal vein", "genetic workup reveals", "inherited condition", "most likely pathophysiology", "patients condition"]}
{"question": "A 78-year-old man is brought to the physician by his daughter because of increasing forgetfulness over the past 5 weeks. He had been living independently but came to live with his daughter temporarily after he complained that he was unable to perform some of his daily activities. He has left the front door wide open and tap water running on multiple occasions. He does not sleep well and wakes up 6–7 times during the night. He does not leave his room and rarely makes conversation with his daughter. He says that he used to enjoy playing the piano but has not played for several months. He has hypertension treated with amlodipine. Vital signs are within normal limits. Mental status examination shows orientation to person, place, and time and psychomotor retardation. He has a blunted affect. Short- and long-term memory is impaired. Attention and concentration are impaired. Neurologic examination shows no focal findings. Serum concentration of electrolytes, thyroid-stimulating hormone, and vitamin B12 are within the reference range. He is very concerned about his memory lapses. Which of the following is the most appropriate treatment for this patient?", "answer": "Fluoxetine", "options": {"A": "Fluoxetine", "B": "Aspirin", "C": "Ventriculoperitoneal shunt", "D": "Memantine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "physician", "daughter", "increasing forgetfulness", "past", "weeks", "living", "to live", "daughter", "unable to perform", "daily activities", "left", "front door wide open", "tap water running", "multiple occasions", "not sleep well", "wakes up 67 times", "night", "not leave", "room", "rarely makes conversation", "daughter", "used", "playing", "piano", "not played", "months", "hypertension treated with amlodipine", "Vital signs", "normal", "Mental shows orientation to person", "place", "time", "psychomotor retardation", "blunted affect", "Short", "long-term memory", "impaired", "Attention", "concentration", "impaired", "Neurologic examination shows", "focal findings", "Serum", "electrolytes", "thyroid-stimulating hormone", "vitamin B12", "reference range", "very concerned", "memory lapses", "following", "most appropriate", "patient"]}
{"question": "A previously healthy 18-month-old boy is brought to the physician by his parents for evaluation of an abdominal mass noticed a few days ago. He appears markedly pale and lethargic. Examination shows a 6-cm, nonmobile mass in the left upper quadrant that crosses the midline. 24-hour urine collection shows elevated homovanillic acid and vanillylmandelic acid. Further evaluation including biopsy confirms the diagnosis of intermediate-risk neuroblastoma. The physician recommends the established standard treatment, which is initiation of neoadjuvant chemotherapy followed by surgical resection, if possible. After a thorough discussion of the risks and benefits of chemotherapy, the likelihood of unresectability without neoadjuvant treatment, and the prognosis without it, the patient's parents steadily refuse chemotherapy because they do not want their son to suffer the side effects. They prefer to take their son home for supportive care only. Which of the following is the most appropriate action by the physician?", "answer": "Seek a court order for neoadjuvant chemotherapy", "options": {"A": "Help the parents to arrange supportive care at home", "B": "Refer the patient to another oncologist", "C": "Recommend for parents to take 2 weeks to think about decision", "D": "Seek a court order for neoadjuvant chemotherapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["healthy", "month old boy", "brought", "physician", "parents", "evaluation", "abdominal mass", "few days", "appears markedly pale", "lethargic", "Examination shows", "mass", "left upper quadrant", "crosses", "midline", "24-hour urine collection shows elevated homovanillic acid", "vanillylmandelic acid", "Further evaluation including biopsy confirms", "diagnosis", "intermediate neuroblastoma", "physician recommends", "established standard treatment", "initiation", "neoadjuvant chemotherapy followed by surgical resection", "possible", "discussion", "risks", "benefits", "chemotherapy", "likelihood", "unresectability", "neoadjuvant treatment", "prognosis", "patient's parents", "refuse chemotherapy", "not", "son to suffer", "side effects", "to take", "son home", "supportive only", "following", "most appropriate action", "physician"]}
{"question": "A laboratory primarily involved with studying cellular proofreading mechanisms is investigating the question of whether the ribosome can recognize a mischarged amino acid and still be incorporated into the growing peptide. In order to do so, they biochemically charge a Lys-tRNA with valine instead of lysine and insert the tRNA into the cell. They design an mRNA sequence that contains only codons for lysine. Which of the following will most likely occur?", "answer": "The mischarged tRNA with valine will be incorporated in the codons that specificy for lysine", "options": {"A": "The ribosome will recognize the mischarged tRNA and prevent its incorporation by removing the valine", "B": "The mischarged tRNA with valine will be incorporated in the codons that specificy for lysine", "C": "The mischarged tRNA will be degraded by the proteasome", "D": "The mischarged tRNA will be removed by the lysyl-tRNA synthetase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["laboratory", "involved", "studying cellular", "mechanisms", "investigating", "question", "ribosome", "amino acid", "peptide", "order", "charge", "Lys tRNA", "valine", "lysine", "insert", "tRNA", "cell", "design", "mRNA sequence", "contains only codons", "lysine", "following", "most likely occur"]}
{"question": "A 65-year-old man with metastatic lung cancer has been experiencing severe, unremitting pain. He has required escalating doses of oral morphine, but is now having dose limiting side-effects. His pain management team recommends using a medication that can reduce his opioid need through interaction with the NMDA-receptor. Which of the following was the most likely recommended agent?", "answer": "Ketamine", "options": {"A": "Propofol", "B": "Ketamine", "C": "Fentanyl", "D": "Midazolam"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65-year-old man", "metastatic lung cancer", "experiencing severe", "pain", "required escalating doses", "oral", "now", "dose limiting side-effects", "pain management team recommends using", "medication", "opioid need", "interaction", "NMDA-receptor", "following", "most likely recommended agent"]}
{"question": "A 27-year-old man presents to the emergency room complaining of left shoulder pain for several weeks. He says that the pain often worsens when he tries to sleep on his left side. Although he tried several pain medications, none of the pain medications helped. He is an amateur tennis player who practices on weekends. He denies any trauma during his practice sessions. On examination of the shoulder joint, severe tenderness was present localized to the greater tuberosity of the left shoulder joint along with biceps tendon tenderness over the bicipital groove. The range of motion was limited to the left side. An X-ray of the joint showed narrowing of the acromiohumeral space with sclerosis and spurring of the acromion. Routine blood test results are normal except for the rheumatoid factor, which is positive. What is the most likely diagnosis?", "answer": "Rotator cuff injury", "options": {"A": "Trauma", "B": "Rheumatoid arthritis", "C": "Osteoarthritis", "D": "Rotator cuff injury"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old man presents", "emergency room", "left shoulder pain", "several weeks", "pain often worsens", "to sleep", "left side", "several pain medications", "pain medications helped", "amateur tennis", "practices", "weekends", "denies", "trauma", "practice sessions", "examination of", "shoulder joint", "severe tenderness", "present localized", "greater tuberosity", "left shoulder joint", "biceps tendon tenderness", "groove", "range of motion", "limited", "left side", "X-ray", "joint showed narrowing", "space", "sclerosis", "spurring", "acromion", "Routine blood test results", "normal", "rheumatoid factor", "positive", "most likely diagnosis"]}
{"question": "A 17-year-old woman presents to your office concerned that she has not had her menstrual period in 4 months. She states that menses began at age of 13 and has been regular until two months ago. She denies sexual activity, and urine pregnancy test is negative. On exam, she appears well-nourished with a BMI of 21 kg/m^2, but you note that she has enlarged cheeks bilaterally and has calluses on the dorsum of her hands. She says that she has been very stressed with school and has recently been binge eating. What other finding do you expect to see in this patient?", "answer": "Erosion of tooth enamel", "options": {"A": "Malar rash", "B": "Increased blood glucose level", "C": "Erosion of tooth enamel", "D": "Elevated estrogen levels"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "office concerned", "not", "menstrual period", "months", "states", "menses began", "age", "regular", "two months", "denies sexual activity", "urine pregnancy test", "negative", "exam", "appears well-nourished", "BMI", "kg/m", "note", "enlarged cheeks", "calluses", "dorsum of", "hands", "very stressed", "school", "recently", "binge eating", "finding", "to see", "patient"]}
{"question": "A 23-year-old college student presents to the clinic with a history of intermittent chest discomfort. He reports that, about once per month for the past 8 or 9 months, he's had episodes of \"feeling like my chest is going to explode.\" During these episodes, he also feels shortness of breath, feels shakiness throughout his arms and legs, and sweats so heavily that he needs to change his shirt. He is unsure of any clear precipitating factors but thinks they may occur more often around important exams or when big school projects are due. He shares that, as these episodes continue to recur, he has had mounting anxiety about having one when he is in class or at a restaurant. As a result, he is leaving the house less and less. He has no past medical history; the physical exam is unremarkable. Which of the following is the best medication for the long-term management of this patient's condition?", "answer": "Citalopram", "options": {"A": "Citalopram", "B": "Lithium", "C": "Propranolol", "D": "Quetiapine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old college student presents", "clinic", "history", "intermittent chest discomfort", "reports", "month", "past", "months", "he", "pisodes of ", "eeling ", "hest ", "pisodes,", "eels  hortness of breath,", "eels  hakiness ", "rms ", "egs,", "weats ", "eeds  o  hange ", "hirt.", "nsure ", "lear  recipitating factors ", "hinks ", "ccur  ore often ", "mportant  xams ", "ig  chool  rojects ", "ue.", "hares ", "pisodes  ontinue  o  ecur,", "ounting  nxiety ", "ne ", "lass ", "estaurant.", "esult,", "ouse ", "ess.", "ast medical history;", "hysical exam ", "nremarkable.", "ollowing ", "est  edication ", "ong-term  anagement ", "atient'", "ndition?"]}
{"question": "A stillborn infant is delivered at 38 weeks' gestation to a 32-year-old woman. The mother had no prenatal care. Examination of the stillborn shows a small pelvis, shallow intergluteal cleft, and club feet. An x-ray shows the absence of the sacrum and lumbar vertebrae. Which of the following is the strongest predisposing factor for this patient's condition?", "answer": "Maternal diabetes", "options": {"A": "Maternal oligohydramnios", "B": "Intrauterine alcohol exposure", "C": "Maternal diabetes", "D": "Chromosome 18 trisomy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["stillborn infant", "delivered", "weeks", "gestation", "year old woman", "mother", "prenatal care", "Examination", "stillborn shows", "small pelvis", "shallow intergluteal cleft", "club feet", "x-ray shows the absence of", "sacrum", "lumbar vertebrae", "following", "strongest predisposing factor", "patient's condition"]}
{"question": "Please refer to the summary above to answer this question\nThe authors of the study have decided to conduct a follow-up analysis on their data. They decide to stratify their results by CD4+T-lymphocyte count at the time of diagnosis. Among patients with CD4+ cell counts below 200/mm3, cART adherence was a significant predictor of DLBCL risk (RR = 0.52, p = 0.01). However, among patients with CD4+ cell counts above 200/mm3, no relationship was found between DLBCL risk and cART adherence (RR = 0.96, p = 0.36). Which of the following explains for the difference observed between the two strata?\"", "answer": "Effect modification", "options": {"A": "Poor generalizability", "B": "Stratified sampling", "C": "Random error", "D": "Effect modification"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["refer", "summary above to answer", "question", "authors", "study", "to conduct", "follow-up analysis", "data", "to", "results", "CD4", "time", "diagnosis", "patients", "CD4", "cell counts", "200 mm3", "cART adherence", "significant predictor", "DLBCL risk", "0", "p", "0.01", "patients", "CD4", "cell counts", "200 mm3", "relationship", "found", "DLBCL risk", "cART adherence", "0 96", "p", "0.36", "following", "difference observed", "two"]}
{"question": "During a Mycobacterium tuberculosis infection, Th1 cells secrete a factor capable of stimulating phagosome-lysosome fusion within macrophages. In addition, the secreted factors help activate macrophages to produce mediators such as NO, which are capable of destroying the invading pathogen. Furthermore, activation of the macrophages by the secreted factor eventually leads to the formation of a tubercle. Which of the following factors is secreted by Th1 cells and responsible for these actions?", "answer": "IFN-gamma", "options": {"A": "IL-4", "B": "TNF-alpha", "C": "IFN-gamma", "D": "Histamine"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Mycobacterium tuberculosis infection", "Th1 cells secrete", "factor capable", "stimulating phagosome-lysosome fusion", "macrophages", "addition", "secreted factors help activate macrophages to", "mediators", "capable", "destroying", "pathogen", "activation", "macrophages", "secreted factor", "leads", "formation", "tubercle", "following factors", "secreted", "Th1 cells", "responsible", "actions"]}
{"question": "A 3-year-old boy is brought to the pediatrician because of abdominal pain and constipation for 3 weeks. His mother says he has been increasingly irritable recently. His vocabulary consists of 50 words and he does not use sentences. Physical examination shows pale conjunctivae and abdominal tenderness. He refers to himself by name but is unable to name body parts or count to three. Peripheral blood smear shows small, pale red blood cells with basophilic stippling. Which of the following processes is most likely impaired in this patient?", "answer": "Conversion of aminolevulinic acid to porphobilinogen", "options": {"A": "Conversion of ferrous iron to ferric iron", "B": "Conversion of porphobilinogen to hydroxymethylbilane", "C": "Conversion of aminolevulinic acid to porphobilinogen", "D": "Conversion of uroporphyrinogen III to coproporphyrinogen III"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "pediatrician", "abdominal pain", "constipation", "weeks", "mother", "irritable recently", "vocabulary consists", "50 words", "not use sentences", "Physical examination shows pale conjunctivae", "abdominal tenderness", "refers", "name", "unable to name body parts", "count", "three", "Peripheral blood shows small", "pale red blood cells", "basophilic stippling", "following processes", "most likely impaired", "patient"]}
{"question": "A group of researchers conducted a study to determine whether there is an association between folic acid supplementation before pregnancy and autism spectrum disorder (ASD) in offspring. The researchers retrospectively surveyed 200 mothers with children diagnosed with ASD during the first 4 years of life and 200 mothers with healthy children. All participants were interviewed about their prenatal consumption of folic acid using standardized questionnaires. A 94% response rate was obtained from the surveys. The study ultimately found that folic acid supplementation was associated with lower rates of ASD in offspring (OR = 0.3, p < 0.01). Which of the following type of bias is most likely to have influenced these results?", "answer": "Recall bias", "options": {"A": "Interviewer bias", "B": "Latency period", "C": "Recall bias", "D": "Survival bias"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A group", "researchers conducted", "study to", "association", "folic acid supplementation", "pregnancy", "autism spectrum disorder", "offspring", "researchers", "surveyed 200 mothers", "children diagnosed", "ASD", "first", "years", "life", "200 mothers", "healthy children", "participants", "interviewed", "prenatal consumption", "folic acid using", "questionnaires", "response rate", "obtained", "surveys", "study", "found", "folic acid supplementation", "associated with lower rates", "ASD", "offspring", "0.3", "p", "0.01", "following type", "bias", "most likely to", "results"]}
{"question": "A student studying pharmacology is a member of a team that is conducting research related to the elimination of multiple anticoagulant medications. His duty as a member of the team is to collect serum samples of the subjects every 4 hours and send them for analysis of serum drug levels. He is also supposed to collect, document and analyze the data. For one of the subjects, he notices that the subject is eliminating 0.5 mg of the drug every 4 hours. Which of the following anticoagulants did this patient most likely consume?", "answer": "Warfarin", "options": {"A": "Warfarin", "B": "Enoxaparin", "C": "Fondaparinux", "D": "Apixaban"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["student studying pharmacology", "member", "team", "conducting research related", "elimination", "multiple anticoagulant medications", "member", "team", "to", "serum samples", "subjects", "4 hours", "send", "analysis", "serum drug levels", "to", "document", "data", "one", "subjects", "subject", "0.5 mg", "drug", "4 hours", "following anticoagulants", "patient most likely"]}
{"question": "A 40-year-old woman presents to her primary care physician for a checkup. She has felt weaker lately and has lost some weight. She denies any urinary issues. Her BUN at her last visit 4 months ago was 45 mg/dL, and her creatinine was 2.0 mg/dL. Her laboratory studies this visit are seen below:\n\nHemoglobin: 8 g/dL\nHematocrit: 29%\nLeukocyte count: 9,500/mm^3 with normal differential\nPlatelet count: 197,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 5.9 mEq/L\nHCO3-: 17 mEq/L\nBUN: 59 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 2.3 mg/dL\nCa2+: 9.0 mg/dL\n\nWhich of the following is the most likely diagnosis?", "answer": "Chronic kidney failure", "options": {"A": "Acute kidney failure", "B": "Chronic kidney failure", "C": "Obstructive uropathy", "D": "Renal cell carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["40 year old woman presents", "primary care physician", "checkup", "felt weaker", "lost", "weight", "denies", "urinary issues", "visit", "months", "mg/dL", "creatinine", "2 0 mg/dL", "laboratory studies", "visit", "seen", "Hemoglobin", "g/dL Hematocrit", "29", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "5", "mEq/L HCO3", "mEq/L", "59 mg/dL Glucose", "99 mg/dL Creatinine", "2.3 mg/dL Ca2", "9 0 mg dL", "following", "most likely diagnosis"]}
{"question": "A 28-year-old woman comes to the obstetrics and gynecology clinic because she has been unsuccessfully trying to conceive with her husband for the last 2 years. He has had 2 children from a previous marriage and has been tested for causes of male infertility. She has had prior abdominal surgery as well as a family history of endocrine abnormalities. Based on this history, a panel of tests are obtained and treatment is started. This treatment will be administered intermittently one week before her normal menstrual cycle. If the most likely drug prescribed in this case was administered in a different manner, which of the following conditions may also be treated by this drug?", "answer": "Prostate cancer", "options": {"A": "Diabetes", "B": "Parkinson disease", "C": "Polycystic ovarian syndrome", "D": "Prostate cancer"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "obstetrics", "gynecology clinic", "to", "husband", "last", "years", "2 children", "previous marriage", "tested", "causes", "male infertility", "prior abdominal surgery", "family history", "endocrine abnormalities", "Based", "history", "panel", "tests", "obtained", "treatment", "started", "treatment", "administered", "one week", "normal menstrual cycle", "most likely drug prescribed", "case", "administered", "different", "following conditions", "treated", "drug"]}
{"question": "A 2-year-old girl with recurrent urinary tract infections is brought to the physician for a follow-up examination. Renal ultrasound shows bilateral dilation of the renal pelvis. A voiding cystourethrography shows retrograde flow of contrast into the ureters during micturition. Histologic examination of a kidney biopsy specimen is most likely to show which of the following findings?", "answer": "Cortical thinning with tubular atrophy", "options": {"A": "Glomerular crescents with macrophages", "B": "Matrix expansion with mesangial proliferation", "C": "Cortical thinning with tubular atrophy", "D": "Thickened glomerular capillary loops"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["2 year old girl", "recurrent urinary tract infections", "brought", "physician", "follow-up examination", "Renal ultrasound shows bilateral dilation", "renal pelvis", "voiding", "shows retrograde flow", "contrast", "ureters", "micturition", "Histologic", "kidney", "most likely to show", "following findings"]}
{"question": "An unconscious 55-year-old man is brought to the Emergency Department by ambulance. He had recently lost his job and his house was about to begin foreclosure. His adult children were concerned for his well being and called the police requesting a welfare check. He was found unresponsive in his gurague. There were several empty bottles of vodka around him and one half empty container of antifreeze. A review of his medical records reveals that he was previously in good health. Upon arrival to the ED he regains consciousness.  His blood pressure is 135/85 mmHg, heart rate 120/min, respiratory rate 22/min, and temperature 36.5°C (97.7°F). On physical exam his speech is slurred and he has difficulty following commands. His abdomen is diffusely tender to palpation with no rebound tenderness. Initial laboratory tests show an elevated serum creatinine (Cr) of 1.9 mg/dL, and blood urea nitrogen (BUN) of 29 mg/dL. Which of the following findings would be expected in this patient’s urine?", "answer": "Calcium oxalate crystals", "options": {"A": "Calcium oxalate crystals", "B": "Hyaline casts", "C": "Urine ketones", "D": "Urate crystals"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["unconscious 55 year old man", "brought", "Emergency Department", "ambulance", "recently lost", "job", "house", "to begin", "adult children", "concerned", "well being", "called", "police requesting", "welfare check", "found unresponsive", "several empty bottles", "vodka", "one half empty container", "antifreeze", "review", "medical records reveals", "good health", "arrival", "ED", "regains consciousness", "blood pressure", "85 mmHg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "physical exam", "speech", "slurred", "difficulty following commands", "abdomen", "tender", "palpation", "rebound tenderness", "Initial laboratory tests show", "elevated serum creatinine", "mg/dL", "blood urea nitrogen", "29 mg/dL", "following findings", "expected", "patients urine"]}
{"question": "A 17-year-old girl comes to the physician because of an 8-month history of severe acne vulgaris over her face, upper back, arms, and buttocks. Treatment with oral antibiotics and topical combination therapy with benzoyl peroxide and retinoid has not completely resolved her symptoms. Examination shows oily skin with numerous comedones, pustules, and scarring over the face and upper back. Long-term therapy is started with combined oral contraceptive pills. This medication decreases the patient's risk developing of which of the following conditions?", "answer": "Ovarian cancer", "options": {"A": "Hypertension", "B": "Ovarian cancer", "C": "Cervical cancer", "D": "Breast cancer"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "physician", "month history", "severe acne vulgaris", "face", "upper back", "arms", "buttocks", "Treatment", "oral antibiotics", "topical combination therapy", "benzoyl peroxide", "retinoid", "not completely resolved", "symptoms", "Examination shows oily skin", "numerous comedones", "pustules", "scarring", "face", "upper back", "Long-term therapy", "started", "combined oral contraceptive pills", "medication decreases", "patient's risk", "following conditions"]}
{"question": "A 48-year-old female presents for a follow-up appointment to discuss her ultrasound results. She presented with a lump in her neck 2 weeks ago. On examination, a thyroid nodule was present; the nodule was fixed, immobile, and non-tender. Ultrasound showed a hypoechoic nodule with a size of 2 cm. Histological examination of a fine needle biopsy was performed and cytological examination reported a likely suspicion of neoplasia. CT scan is performed to check for any lesions in the bones and/or lungs, common metastatic sites in this condition. Treatment with radioiodine therapy is planned after near-total thyroidectomy. Considering this tumor, which of the following is the most likely initial metastatic site in this patient?", "answer": "Inferior thyroid arteries", "options": {"A": "Trachea", "B": "Cervical lymph nodes", "C": "Inferior thyroid arteries", "D": "Thyrohyoid muscle"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old female presents", "follow-up appointment to discuss", "ultrasound results", "presented", "lump", "neck", "weeks", "examination", "thyroid nodule", "present", "nodule", "fixed", "immobile", "non-tender", "Ultrasound showed", "nodule", "size of", "Histological examination", "fine needle biopsy", "performed", "cytological examination reported", "likely suspicion", "neoplasia", "CT scan", "performed to check", "lesions", "bones", "lungs", "common metastatic sites", "condition", "Treatment", "radioiodine therapy", "planned", "total thyroidectomy", "Considering", "tumor", "following", "most likely initial metastatic site", "patient"]}
{"question": "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?", "answer": "Benznidazole", "options": {"A": "Benznidazole", "B": "Ivermectin", "C": "Mebendazol", "D": "Sodium stibogluconate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care physician", "severe headaches", "fever", "2 days", "right eyelid", "swelling", "starting to block", "vision", "eye", "recently returned", "tour", "world", "visited Thailand", "Ethiopia", "Brazil", "past medical history", "unremarkable", "presentation", "temperature", "blood pressure", "81 mmHg", "pulse", "min", "respirations", "min", "Physical exam reveals", "nontender swelling of", "right eyelid", "lymphadenopathy", "indurated red patch", "surrounding erythema", "local", "left", "following drugs", "used to treat", "patient's condition"]}
{"question": "A 10-year-old Caucasian female with Turner's syndrome underwent an abdominal imaging study and was discovered that the poles of her kidneys were fused inferiorly. Normal ascension of kidney during embryological development would be prevented by which of the following anatomical structures?", "answer": "Inferior mesenteric artery", "options": {"A": "Superior mesenteric artery", "B": "Inferior mesenteric artery", "C": "Celiac artery", "D": "Splenic artery"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A 10 year old Caucasian female", "Turner's syndrome", "abdominal imaging study", "discovered", "poles of", "kidneys", "fused", "Normal", "kidney", "embryological development", "prevented", "following anatomical structures"]}
{"question": "A 34-year-old woman is assaulted and suffers a number of stab wounds to her abdomen. Bystanders call paramedics and she is subsequently taken to the nearest hospital. On arrival to the emergency department, her vitals are T: 36 deg C, HR: 110 bpm, BP: 100/60, RR: 12, SaO2: 99%. A FAST and abdominal CT are promptly obtained which are demonstrated in Figures A and B, respectively. Her chart demonstrates no other medical problems and vaccinations/boosters up to date. The patient is diagnosed with a Grade V splenic laceration and is immediately brought to the OR for emergent splenectomy. The splenectomy is successfully performed with removal of the damaged spleen (Figure C). Following the operation, the patient should receive which of the following vaccines: (I) H. influenzae (II) Tetanus (III) N. meningitidis (IV) S. pneumoniae (V) Hepatitis B", "answer": "I, III, IV", "options": {"A": "I, II", "B": "I, III, IV", "C": "I, V", "D": "III, IV"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "assaulted", "suffers", "number", "stab wounds", "abdomen", "Bystanders call paramedics", "taken", "nearest hospital", "arrival", "emergency department", "T", "36 deg", "BP", "100 60", "99", "FAST", "abdominal CT", "obtained", "chart demonstrates", "medical problems", "vaccinations boosters", "date", "patient", "diagnosed", "a Grade V splenic", "immediately brought", "emergent splenectomy", "splenectomy", "performed", "removal", "damaged spleen", "Following", "operation", "patient", "receive", "following vaccines", "I", "H", "influenzae", "Tetanus", "III", "N", "meningitidis", "IV", "pneumoniae", "Hepatitis B"]}
{"question": "Researchers are studying the inheritance pattern of mutations in the cystic fibrosis transmembrane regulator (CFTR) gene, the gene responsible for cystic fibrosis. It is believed that, in addition to the commonly found ΔF508 mutation, a novel mutation in this gene is found in a particular population under study. Which of the following would most likely suggest that these two loci have a high probability of being closely linked?", "answer": "LOD Score > 3", "options": {"A": "LOD Score < 1", "B": "LOD Score < 2", "C": "LOD Score > 3", "D": "LOD Score = 0"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Researchers", "studying", "inheritance pattern", "mutations", "cystic fibrosis transmembrane regulator", "gene", "gene responsible", "cystic fibrosis", "found", "mutation", "novel mutation", "gene", "found", "population", "study", "following", "most likely suggest", "two loci", "high probability", "linked"]}
{"question": "A 28-year-old woman returns to the clinic to follow up on a recent abnormal cervical biopsy that demonstrated cervical intraepithelial neoplasia (CIN) I. The patient is quite anxious about the implications of this diagnosis. Her physical examination is within normal limits. Her vital signs do not show any abnormalities at this time. Her past medical, family, and social histories are all non-contributory. Which of the following is the appropriate management of a newly diagnosed CIN I in a 24-year-old patient?", "answer": "Close observation, pap smear screening at 6 and 12 months, and HPV DNA testing at 12 months", "options": {"A": "Close observation, pap smear screening at 6 and 12 months, and HPV DNA testing at 12 months", "B": "Cryotherapy ablation", "C": "Loop electrosurgical excision (LEEP)", "D": "Hysterectomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman returns", "clinic to follow up", "recent abnormal cervical biopsy", "cervical intraepithelial neoplasia", "I", "patient", "anxious", "diagnosis", "physical examination", "normal limits", "vital signs", "not show", "abnormalities", "time", "past medical", "family", "social histories", "non contributory", "following", "appropriate management", "newly diagnosed CIN I", "year old patient"]}
{"question": "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?", "answer": "Inhibits viral assembly", "options": {"A": "Prevents viral transcription", "B": "Inhibits viral assembly", "C": "Inhibits viral entry", "D": "Prevents T-cell binding"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["clinical researcher", "interested", "creating", "new drug", "HIV patients", "Darunavir", "efficacious", "recent patients", "experienced", "increased incidence", "hyperglycemia", "new drug called", "same mechanism of action", "darunavir", "fewer side effects", "following", "mechanism of action"]}
{"question": "A 58-year-old white man with hypertension and type 2 diabetes mellitus comes to the physician because of a 3-month history of a painless lesion on his lower lip. He has smoked one pack of cigarettes daily for 20 years. He has worked as a fruit picker for the past 25 years. His current medications include captopril and metformin. Examination of the oral cavity shows a single ulcer near the vermillion border. Which of the following is the most likely diagnosis?", "answer": "Squamous cell carcinoma", "options": {"A": "Squamous cell carcinoma", "B": "Aphthous stomatitis", "C": "Actinic keratosis", "D": "Traumatic ulcer"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old white man", "hypertension", "type 2 diabetes mellitus", "physician", "3 month history", "painless lesion", "lower lip", "smoked one pack", "cigarettes daily", "20 years", "worked", "fruit", "past", "years", "current medications include captopril", "metformin", "Examination", "oral cavity shows", "single ulcer", "border", "following", "most likely diagnosis"]}
{"question": "An investigator is studying the effect of drug X on the retinoblastoma (Rb) gene on chromosome 13 in endometrial cells. Endometrial cells obtained from study participants are plated on growth media and the distribution of cell cycle phase is measured with flow cytometry. Drug X, which is known to activate cyclin-dependent kinase 4, is administered to all the cells, and the distribution of cell cycle phase is measured again 1 hour later. Which of the following is most likely to result from the action of drug X on the Rb gene?", "answer": "Initiation of S phase", "options": {"A": "G1 phase arrest", "B": "Prophase I arrest", "C": "Initiation of S phase", "D": "Completion of G2 phase"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying", "effect of drug", "retinoblastoma", "gene", "chromosome 13", "endometrial cells", "obtained", "study participants", "plated", "growth media", "distribution", "cell cycle phase", "measured", "flow cytometry", "Drug X", "known to activate cyclin-dependent kinase 4", "administered", "cells", "distribution", "cell cycle phase", "measured", "hour later", "following", "most likely to result", "action of drug", "Rb gene"]}
{"question": "A 65-year-old man presents with painless swelling of the neck over the past week. He also says he has been having intermittent fevers and severe night sweats which require a change of bed sheets the next day. His past medical history is significant for human immunodeficiency virus (HIV) diagnosed 10 years ago with which he admits to not always being compliant with his antiretroviral medication. The patient reports a 20-pack-year smoking history but no alcohol or recreational drug use. A review of systems is significant for a 6 kg (13.2 lb) unintentional weight loss over the past 2 months. The vital signs include: temperature 37.8℃ (100.0℉) and blood pressure 120/75 mm Hg. On physical examination, there are multiple non-tender swollen lymph nodes averaging 2 cm in diameter that is palpable in the anterior and posterior triangles of the neck bilaterally. Axillary and inguinal lymphadenopathy is present on the right side. A cardiopulmonary exam is unremarkable. The spleen size is 16 cm on percussion. Laboratory studies show the following:\nHemoglobin 9 g/dL\nMean corpuscular volume 88 μm3\nLeukocyte count 18,000/mm3\nPlatelet count 130,000/mm3\n    Serum creatinine 1.1 mg/dL\nSerum lactate dehydrogenase 1,000 U/L\nAn excisional biopsy of a superficial axillary lymph node on the right is performed and a histopathologic analysis confirms the most likely diagnosis. Which of the following is the next best diagnostic step in the workup of this patient?", "answer": "Hepatitis C virus antibodies", "options": {"A": "Antinuclear antibody", "B": "Hepatitis C virus antibodies", "C": "JAK-2 mutation", "D": "Tartrate-resistant acid phosphatase (TRAP) test"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "painless swelling of the neck", "past week", "intermittent fevers", "severe night sweats", "change", "bed sheets", "next day", "past medical history", "significant", "human immunodeficiency virus", "diagnosed 10 years", "admits to not always", "compliant", "antiretroviral medication", "patient reports", "20 smoking history", "alcohol", "recreational drug use", "review of systems", "significant", "kg", "unintentional weight loss", "past", "months", "vital signs include", "temperature", "100 0", "blood pressure", "75 mm Hg", "physical examination", "multiple non-tender swollen lymph nodes averaging 2", "diameter", "palpable", "anterior", "posterior triangles of", "neck", "Axillary", "inguinal lymphadenopathy", "present", "right side", "cardiopulmonary exam", "unremarkable", "spleen size", "percussion", "Laboratory studies show", "following", "Hemoglobin", "g", "Mean corpuscular volume", "Leukocyte 18", "mm3 Platelet count", "Serum", "lactate dehydrogenase", "U/L", "excisional", "superficial axillary", "right", "performed", "histopathologic analysis confirms", "most likely diagnosis", "following", "next best diagnostic step", "workup", "patient"]}
{"question": "In order to assess the feasibility and evaluate the outcomes of cerclage wiring as a supportive approach to osteosynthesis in femur fractures, a group of orthopedic surgeons studied 14 patients with primary and periprosthetic fractures of the thigh bone. Parameters such as patient demographic, type of implant, number of wires used, fracture union rate, and potential complications were thoroughly recorded and analyzed in all the patients, with a mean duration of patient follow-up of 16 months. Union was achieved in all patients with a mean duration of 90 days, and there were no complications found in patients included in the study. The authors were satisfied with their findings and, due to the prospective nature of their research, submitted their study to a journal as a cohort study (which they noted in the study title as well). However, the journal editor returned the article, suggesting that it should be submitted as a case series instead. The editor made this suggestion to the authors for which of the following reasons?", "answer": "Lack of risk calculation", "options": {"A": "No prevalence assessment", "B": "Low number of patients", "C": "Ascertainment bias", "D": "Lack of risk calculation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["order to assess", "evaluate", "outcomes", "cerclage wiring", "supportive approach", "osteosynthesis", "femur fractures", "a group", "orthopedic surgeons studied", "patients", "primary", "periprosthetic fractures of", "thigh bone", "Parameters", "as patient demographic", "type of implant", "number of wires used", "fracture union rate", "potential complications", "recorded", "analyzed", "patients", "mean duration", "patient follow-up", "months", "Union", "patients", "mean duration", "90 days", "complications found", "patients included", "study", "authors", "satisfied", "findings", "due to", "prospective nature", "research", "submitted", "study", "journal", "cohort study", "noted", "study title", "well", "journal editor returned", "article", "suggesting", "submitted", "case series", "editor made", "suggestion", "authors", "following reasons"]}
{"question": "A 67-year-old woman presents from home hospice with a change in her mental status. She has seemed more confused lately and is unable to verbalize her symptoms. Her temperature is 102°F (38.9°C), blood pressure is 117/65 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 95% on room air. Physical exam is notable for a right upper quadrant mass that elicits discomfort when palpated. Ultrasound is notable for pericholecystic fluid and gallbladder wall thickening without any gallstones. Which of the following is the most likely diagnosis?", "answer": "Acalculous cholecystitis", "options": {"A": "Acalculous cholecystitis", "B": "Calculous cholescystitis", "C": "Choledocholithiasis", "D": "Emphysematous cholecystitis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old woman presents", "home hospice", "change in", "mental status", "more confused", "unable to", "symptoms", "temperature", "blood pressure", "65 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "95", "room air", "Physical exam", "notable", "right upper quadrant mass", "elicits discomfort", "palpated", "Ultrasound", "notable", "fluid", "gallbladder wall thickening", "gallstones", "following", "most likely diagnosis"]}
{"question": "A 35-year-old female is brought to the emergency department after being found unconscious. The patient is found to have a blood glucose level of 35 mg/dL. Hgb A1c was found to be 5.1%. C-peptide level was found to be decreased. The patient returned to her baseline after glucose replacement. She states that she has never had an episode like this before. She has no significant past medical history but reports a family history of diabetes in her mother. She states that she has been undergoing a difficult divorce over the past few months. What is the likely cause of this patient's condition?", "answer": "Factitious disorder", "options": {"A": "Insulinoma", "B": "Factitious disorder", "C": "Hypothyroidism", "D": "Somatization disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old female", "brought", "emergency department", "found unconscious", "patient", "found to", "blood glucose level", "35 mg/dL", "Hgb A1c", "found to", "5", "C-peptide level", "found to", "decreased", "patient returned", "baseline", "glucose replacement", "states", "never", "episode", "significant past medical history", "reports", "family history", "diabetes", "mother", "states", "difficult divorce", "past", "months", "likely cause", "patient's condition"]}
{"question": "A 45-year-old man presents to the physician with complaints of increased urinary frequency and decreasing volumes for the past 2 months. He does not complain of any pain during urination. He is frustrated that he has to wake up 2 or 3 times per night to urinate even though he tried reducing the amount of water he consumes before bed and made some other dietary changes without any improvement. He has no family history of prostate disease. Physical examination is negative for any suprapubic mass or tenderness, and there is no costovertebral angle tenderness. Which of the following is the best next step in the management of this patient?", "answer": "Digital rectal examination", "options": {"A": "Urinalysis and serum creatinine", "B": "Reassurance", "C": "Digital rectal examination", "D": "Prostate-specific antigen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "complaints", "increased urinary frequency", "decreasing volumes", "past 2 months", "not", "pain", "urination", "frustrated", "to wake up", "3", "night to", "reducing", "amount", "water", "bed", "made", "dietary changes", "improvement", "family history of prostate disease", "Physical examination", "negative", "suprapubic mass", "tenderness", "costovertebral angle tenderness", "following", "best next step", "management", "patient"]}
{"question": "A 48-year-old woman with chronic tension headaches comes to the physician because of several episodes of bilateral flank pain and reddish urine within the past month. Current medications include aspirin, which she takes almost daily for headaches. Her temperature is 37.4°C (99.3°F) and her blood pressure is 150/90 mm Hg. Physical examination shows costovertebral tenderness to percussion bilaterally. Laboratory studies show a hemoglobin concentration of 10.2 g/dL and serum creatinine concentration of 2.4 mg/dL. Urine studies show:\nUrine\nProtein\n3+\nRBC > 16/hpf\nWBC 2/hpf\nThere are no casts or dysmorphic RBCs visualized on microscopic analysis of the urine. Which of the following is the most likely underlying cause of this patient's hematuria?\"", "answer": "Vasoconstriction of the medullary vessels", "options": {"A": "Tubular lumen obstruction by protein casts", "B": "Necrotizing inflammation of the renal glomeruli", "C": "Bacterial infection of the renal parenchyma", "D": "Vasoconstriction of the medullary vessels"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["48 year old woman", "chronic tension headaches", "physician", "of several episodes", "bilateral flank pain", "urine", "past month", "Current medications include aspirin", "takes almost daily", "headaches", "temperature", "4C", "99", "blood pressure", "90 mm Hg", "Physical examination shows", "tenderness", "percussion", "Laboratory studies show a hemoglobin concentration", "10 2 g dL", "serum creatinine concentration", "mg dL", "Urine studies show", "Urine", "RBC", "hpf WBC", "casts", "dysmorphic RBCs visualized", "microscopic analysis", "urine", "following", "most likely underlying cause", "patient", "ematuria?"]}
{"question": "A 37-year-old primigravid woman at 12 weeks' gestation comes to the emergency department because of vaginal bleeding and dull suprapubic pain for 3 hours. She has had spotting during the last 3 days. Her medications include folic acid and a multivitamin. She has smoked one pack of cigarettes daily for 15 years. Her temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure is 89/65 mm Hg. Pelvic examination shows a dilated cervical os and a uterus consistent in size with an 11-week gestation. Ultrasonography shows an embryo of 4 cm in crown-rump length and no fetal cardiac activity. Which of the following is the most appropriate next step in management?", "answer": "Dilation and curettage", "options": {"A": "Misoprostol therapy", "B": "Methotrexate therapy", "C": "Dilation and curettage", "D": "Complete bed rest"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old primigravid woman", "weeks", "gestation", "emergency department", "vaginal bleeding", "dull suprapubic", "hours", "spotting", "3 days", "medications include folic acid", "multivitamin", "smoked one pack", "cigarettes daily", "years", "temperature", "98", "pulse", "min", "blood pressure", "65 mm Hg", "Pelvic examination shows", "dilated cervical os", "uterus consistent", "size", "week gestation", "Ultrasonography shows", "embryo", "crown-rump length", "fetal cardiac", "following", "most appropriate next step", "management"]}
{"question": "A 17-year-old female accidentally eats a granola bar manufactured on equipment that processes peanuts. She develops type I hypersensitivity-mediated histamine release, resulting in pruritic wheals on the skin. Which of the following layers of this patient's skin would demonstrate histologic changes on biopsy of her lesions?", "answer": "Dermis", "options": {"A": "Stratum corneum", "B": "Stratum granulosum", "C": "Stratum basale", "D": "Dermis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "eats", "manufactured", "equipment", "processes peanuts", "type I hypersensitivity mediated histamine release", "resulting in", "wheals", "skin", "of", "following layers", "patient's skin", "histologic changes", "biopsy", "lesions"]}
{"question": "A 4-year-old girl is brought to the emergency department with a persistent cough, fever, and vomiting. The past year the child has been admitted to the hospital 3 times with pneumonia. For the past 1 week, the child has been experiencing thick purulent cough and says that her chest feels ‘heavy’. Her stools have been loose and foul-smelling over the past week. Her parents are also concerned that she has not gained much weight due to her frequent hospital visits. She was born at 39 weeks gestation via spontaneous vaginal delivery and is up to date on all vaccines and is meeting all developmental milestones. On physical exam, the temperature is 39.1°C (102.4°F). She appears lethargic and uncomfortable. Crackles are heard in the lower lung bases, with dullness to percussion. A small nasal polyp is also present on inspection. Which of the following is the most likely cause for the girl’s symptoms?", "answer": "Dysfunction in a transmembrane regulator", "options": {"A": "Dysfunction in a transmembrane regulator", "B": "Inefficient breakdown of leucine, isoleucine, and valine", "C": "Dysfunction in the motility of respiratory cilia", "D": "Deficiency in lymphocytic activity"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["4 year old girl", "brought", "emergency department", "persistent cough", "fever", "vomiting", "past year", "child", "admitted", "hospital", "times", "pneumonia", "past", "week", "child", "experiencing thick purulent cough", "chest feels heavy", "stools", "loose", "smelling", "past week", "parents", "concerned", "not gained", "weight due to", "frequent hospital visits", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "meeting", "developmental milestones", "physical exam", "temperature", "4F", "appears lethargic", "Crackles", "heard", "lower lung bases", "dullness", "percussion", "small nasal polyp", "present", "inspection", "following", "most likely cause", "girls symptoms"]}
{"question": "A 48-year-old man seeks evaluation at a clinic with a complaint of breathlessness for the past couple of weeks. He says that he finds it difficult to walk a few blocks and has to rest. He also complains of a cough for the past 3 months, which is dry and hacking in nature. The medical history is relevant for an idiopathic arrhythmia for which he takes amiodarone daily. He is a non-smoker and does not drink alcohol. He denies any use of illicit drugs. The vital signs are as follows: heart rate 98/min, respiratory rate 16/min, temperature 37.6°C (99.68°F), and blood pressure 132/70 mm Hg. The physical examination is significant for inspiratory crackles over the lung bases. An echocardiogram shows a normal ejection fraction. A chest radiograph is performed and shown below. Which of the following findings will most likely be noted on spirometry?", "answer": "Decreased FEV1 and FVC with normal FEV1/FVC ratio", "options": {"A": "Decreased FEV1 and normal FVC", "B": "Decreased FEV1 and FVC with decreased FEV1/FVC ratio", "C": "Decreased FEV1 and FVC with normal FEV1/FVC ratio", "D": "Increased FEV1 and FVC"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["48 year old man", "evaluation", "clinic", "complaint", "breathlessness", "past couple", "weeks", "finds", "difficult to walk", "few blocks", "to rest", "cough", "past 3 months", "dry", "nature", "medical history", "relevant", "idiopathic arrhythmia", "takes amiodarone daily", "non-smoker", "not drink alcohol", "denies", "use", "illicit drugs", "vital signs", "follows", "heart rate 98 min", "respiratory rate", "min", "temperature", "99", "blood pressure", "70 mm Hg", "physical examination", "significant", "inspiratory crackles", "lung bases", "echocardiogram shows", "normal ejection fraction", "chest radiograph", "performed", "shown", "following findings", "most likely", "noted", "spirometry"]}
{"question": "A 2,300 g (5 lb) male newborn is delivered to a 29-year-old primigravid woman. The mother has HIV and received triple antiretroviral therapy during pregnancy. Her HIV viral load was 678 copies/mL 1 week prior to delivery. Labor was uncomplicated. Apgar scores were 7 and 8 at 1 and 5 minutes respectively. Physical examination of the newborn shows no abnormalities. Which of the following is the most appropriate next step in the management of this infant?", "answer": "Administer zidovudine", "options": {"A": "Administer zidovudine", "B": "HIV DNA testing", "C": "HIV RNA testing", "D": "Reassurance and follow-up"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2 300 g", "5", "male newborn", "delivered", "29 year old primigravid woman", "mother", "HIV", "received triple antiretroviral therapy", "pregnancy", "HIV viral load", "copies/mL 1 week prior to delivery", "Labor", "uncomplicated", "Apgar scores", "8", "1", "5 minutes", "Physical", "newborn shows", "abnormalities", "following", "most appropriate next step", "management", "infant"]}
{"question": "A 60-year-old woman presents to a physician for worsening shortness of breath and increasing abdominal distention over the last 3 months. She says that the shortness of breath is worse on exertion and improves with rest. While she could previously walk to the nearby store for her groceries, she now has to drive because she gets ''winded'' on the way. The patient was diagnosed with diabetes 5 years ago and is compliant with her medications. The medical history is otherwise unremarkable. The physical examination reveals gross ascites and visibly engorged periumbilical veins. Bilateral pitting edema is noted around the ankles. The finger-prick blood glucose level is 100 mg/dL. What is the mechanism of action of the anti-diabetic medication this patient is most likely taking?", "answer": "Increased gene expression of GLUT-4", "options": {"A": "Binding to the alpha subunit of the insulin receptor", "B": "Closure of ATP-sensitive K-channels in the pancreatic beta-cell", "C": "Increased gene expression of GLUT-4", "D": "Glucagon-like peptide-1 receptor agonist"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old woman presents", "physician", "worsening shortness of breath", "increasing abdominal distention", "months", "shortness of breath", "worse", "exertion", "improves", "rest", "walk", "store", "now", "to drive", "gets", "winded", "patient", "diagnosed", "diabetes", "years", "compliant", "medications", "medical history", "unremarkable", "physical examination reveals gross ascites", "engorged periumbilical veins", "Bilateral pitting edema", "noted", "ankles", "finger-prick blood glucose level", "100 mg/dL", "mechanism of action", "diabetic medication", "patient", "most likely"]}
{"question": "A 15-year-old girl comes to the physician because of episodic pelvic pain radiating to her back and thighs for 4 months. The pain occurs a few hours before her menstrual period and lasts for 2 days. She has been taking ibuprofen, which has provided some relief. Menses have occurred at regular 28-day intervals since menarche at the age of 12 years and last for 5 to 6 days. She is sexually active with two male partners and uses condoms inconsistently. Vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Endometrial sloughing and uterine contractions mediated by prostaglandin", "options": {"A": "Endometrial sloughing and uterine contractions mediated by prostaglandin", "B": "Ascending infection of the uterus, fallopian tubes, ovaries, or surrounding tissue", "C": "Fluid-filled sac within the ovary", "D": "Hormone-sensitive smooth muscle tumor of the myometrium"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "physician", "of episodic pelvic radiating to", "back", "thighs", "months", "pain occurs", "few hours", "menstrual period", "lasts", "2 days", "taking ibuprofen", "provided", "relief", "Menses", "occurred", "regular", "day intervals", "menarche at", "age", "years", "last", "6 days", "sexually active", "two male partners", "uses condoms", "Vital signs", "normal", "Physical examination shows", "abnormalities", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 25-year-old male is hospitalized for acute agitation, photophobia, and dysphagia. His parents report that he has been experiencing flu-like symptoms for one week prior to hospital admission. Five weeks ago, the patient was in Mexico, where he went on several spelunking expeditions with friends. The patient ultimately becomes comatose and dies. Autopsy of brain tissue suggests a viral infection. The likely causal virus spreads to the central nervous system (CNS) in the following manner:", "answer": "Retrograde migration up peripheral nerve axons", "options": {"A": "Hematogenous dissemination to the meninges", "B": "Retrograde migration up peripheral nerve axons", "C": "Reactivation of virus previously latent in dorsal root ganglia", "D": "Infection of oligodendrocytes and astrocytes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old male", "hospitalized", "acute agitation", "photophobia", "dysphagia", "parents report", "experiencing flu-like symptoms", "one week", "hospital admission", "Five weeks", "patient", "Mexico", "spelunking expeditions", "friends", "patient", "comatose", "Autopsy", "brain suggests", "viral infection", "likely causal virus spreads", "central nervous system", "following"]}
{"question": "A 19-year-old Caucasian male presents to your office with hypopigmented skin. He undergoes a skin biopsy and is found to have an absence of melanocytes in the epidermis. Which of the following is the most likely diagnosis?", "answer": "Vitiligo", "options": {"A": "Tinea versicolor", "B": "Albinism", "C": "Vitiligo", "D": "Melanoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old Caucasian male presents", "office", "hypopigmented skin", "skin biopsy", "found to", "absence", "melanocytes", "epidermis", "following", "most likely diagnosis"]}
{"question": "A 51-year-old man presents for a routine check-up. He has no complaints. At his last annual visit, his physical and laboratory tests were unremarkable. His past medical history is significant for hypercholesterolemia, well managed with rosuvastatin, and hypertension, well managed with hydrochlorothiazide. His current medications also include aspirin. The patient is afebrile, and his vital signs are within normal limits. Physical examination is unremarkable. His laboratory tests are significant for the following:\nWBC 29,500/mm3\nHematocrit 26.1%\nHemoglobin 9.1 g/dL\nPlatelet count 298,000/mm3\nA peripheral blood smear and differential shows 92% small normocytic lymphocytes. The patient’s diagnosis in confirmed by bone marrow biopsy and flow cytometry. He is monitored through regular follow-up visits. Three years after the initial diagnosis, the patient presents with swollen cervical and axillary lymph nodes, unintentional weight loss of 4.5 kg (approx. 10 lb), and “rib pain” on his right side. On physical examination, there is palpable, firm, non-tender cervical and axillary lymphadenopathy bilaterally. He also has moderate splenomegaly, which, when palpated, elicits pain. Which of the following is the best treatment for this patient’s most likely diagnosis?", "answer": "Fludarabinern", "options": {"A": "Bleomycinrn", "B": "Imatinib", "C": "Fludarabinern", "D": "Vincristinern"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "routine check-up", "complaints", "last annual visit", "physical", "laboratory tests", "unremarkable", "past medical history", "significant", "hypercholesterolemia", "well managed", "rosuvastatin", "hypertension", "well managed", "hydrochlorothiazide", "current medications", "include aspirin", "patient", "afebrile", "vital signs", "normal limits", "Physical examination", "unremarkable", "laboratory tests", "significant", "following", "WBC 29 500 mm3 Hematocrit", "Hemoglobin", "g dL Platelet count 298", "peripheral blood smear", "differential shows", "small normocytic lymphocytes", "patients diagnosis", "confirmed by bone marrow biopsy", "flow cytometry", "monitored", "regular follow-up visits", "Three years", "initial diagnosis", "patient presents", "swollen cervical", "axillary lymph nodes", "unintentional weight loss", "kg", "10", "rib pain on", "right side", "physical examination", "palpable", "firm", "non-tender cervical", "axillary lymphadenopathy", "moderate splenomegaly", "palpated", "elicits pain", "following", "best treatment", "patients", "likely diagnosis"]}
{"question": "A 62-year-old woman is evaluated because of a 3-day history of headache, nausea, and decreased urination. Laboratory studies show:\nSerum\nNa+ 136 mEq/L\nK+ 3.2 mEq/L\nCl- 115 mEq/L\nMg2+ 1.4 mEq/L\nUrine\npH 7.0\nArterial blood gas analysis on room air shows a pH of 7.28 and a HCO3- concentration of 14 mEq/L. Prolonged treatment with which of the following drugs would best explain this patient's findings?\"", "answer": "Amphotericin B", "options": {"A": "Trimethoprim-sulfamethoxazole", "B": "Eplerenone", "C": "Amphotericin B", "D": "Heparin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old woman", "evaluated", "of", "3-day history", "headache", "nausea", "decreased urination", "Laboratory studies show", "Serum", "mEq/L K", "Mg2", "Urine pH 7.0 Arterial blood gas analysis", "room air shows", "pH", "7", "HCO3", "concentration", "mEq/L", "Prolonged treatment", "following drugs", "best", "patient", "indings?"]}
{"question": "A 21-year-old male presents to his primary care provider for fatigue. He reports that he graduated from college last month and returned 3 days ago from a 2 week vacation to Vietnam and Cambodia. For the past 2 days, he has developed a worsening headache, malaise, and pain in his hands and wrists. The patient has a past medical history of asthma managed with albuterol as needed. He is sexually active with both men and women, and he uses condoms “most of the time.” On physical exam, the patient’s temperature is 102.5°F (39.2°C), blood pressure is 112/66 mmHg, pulse is 105/min, respirations are 12/min, and oxygen saturation is 98% on room air. He has tenderness to palpation over his bilateral metacarpophalangeal joints and a maculopapular rash on his trunk and upper thighs. Tourniquet test is negative. Laboratory results are as follows:\n\nHemoglobin: 14 g/dL\nHematocrit: 44%\nLeukocyte count: 3,200/mm^3\nPlatelet count: 112,000/mm^3\n\nSerum:\nNa+: 142 mEq/L\nCl-: 104 mEq/L\nK+: 4.6 mEq/L\nHCO3-: 24 mEq/L\nBUN: 18 mg/dL\nGlucose: 87 mg/dL\nCreatinine: 0.9 mg/dL\nAST: 106 U/L\nALT: 112 U/L\nBilirubin (total): 0.8 mg/dL\nBilirubin (conjugated): 0.3 mg/dL\n\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Chikungunya", "options": {"A": "Chikungunya", "B": "Dengue fever", "C": "Epstein-Barr virus", "D": "Hepatitis A"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["21-year-old male presents", "primary care provider", "fatigue", "reports", "graduated", "college", "month", "returned 3 days", "2 week vacation", "Vietnam", "Cambodia", "past 2 days", "worsening headache", "malaise", "pain", "hands", "wrists", "patient", "past medical managed", "albuterol as needed", "sexually active with", "men", "women", "uses condoms", "time", "physical exam", "patients temperature", "blood pressure", "66 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "tenderness", "palpation", "bilateral metacarpophalangeal joints", "maculopapular rash", "trunk", "upper thighs", "Tourniquet test", "negative", "Laboratory results", "follows", "Hemoglobin", "g/dL Hematocrit", "Leukocyte count", "3 200 mm 3 Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "mEq/L K", "4.6 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "87 mg/dL Creatinine", "0.9 mg/dL AST", "U/L ALT", "U/L Bilirubin", "total", "0.8 mg/dL Bilirubin", "conjugated", "0.3 mg/dL", "following", "most likely diagnosis", "patient"]}
{"question": "Three days after admission to the intensive care unit for septic shock and bacteremia from a urinary tract infection, a 34-year-old woman has persistent hypotension. Her blood cultures are positive for Escherichia coli, for which she has been receiving appropriate antibiotics since admission. She has no history of any serious illness. She does not use illicit drugs. Current medications include norepinephrine, ceftriaxone, and acetaminophen. She appears well. Her temperature is 37.5°C (99.5°F), heart rate is 96/min, and blood pressure is 85/55 mm Hg. Examination of the back shows costovertebral tenderness bilaterally. Examination of the thyroid gland shows no abnormalities. Laboratory studies show:\n  Hospital day 1 Hospital day 3\nLeukocyte count 18,500/mm3 10,300/mm3\nHemoglobin 14.1 mg/dL 13.4 mg/dL\nSerum\nCreatinine 1.4 mg/dL 0.9 mg/dL\nFasting glucose 95 mg/dL 100 mg/dL\nTSH   1.8 µU/mL\nT3, free   0.1 ng/dL\nT4, free   0.9 ng/dL\nRepeat blood cultures are negative. A chest X-ray shows no abnormalities. Which of the following is the most appropriate treatment?", "answer": "Treating the underlying illness", "options": {"A": "Bromocriptine", "B": "Levothyroxine", "C": "Removing toxic drugs", "D": "Treating the underlying illness"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Three days", "admission", "intensive care unit", "septic shock", "bacteremia", "urinary tract infection", "year old woman", "persistent hypotension", "blood cultures", "positive", "Escherichia coli", "receiving appropriate antibiotics", "admission", "history", "serious illness", "not use illicit drugs", "Current medications include norepinephrine", "ceftriaxone", "acetaminophen", "appears well", "temperature", "99", "heart rate", "96 min", "blood pressure", "85 55 mm Hg", "Examination of", "back shows", "tenderness", "Examination of", "thyroid gland shows", "abnormalities", "Laboratory studies show", "Hospital day", "Leukocyte 18 500 mm3 10 300", "Hemoglobin", "mg", "13.4 mg", "Creatinine", "Fasting", "95", "100", "8", "mL", "free", "0.1 ng/dL T4", "free", "0.9 ng/dL Repeat blood", "negative", "chest X-ray shows", "abnormalities", "following", "most appropriate treatment"]}
{"question": "An 11-year-old child complains of pain in the leg while playing. Blood pressure in the upper limb is 140/90 mm Hg and lower limbs are 110/70 mm Hg. There is a brachiofemoral delay in the pulse. Auscultation shows a loud S1, loud S2, and S4. There is a presence of an ejection systolic murmur in the interscapular area. Chest X-ray reveals the notching of the ribs. What is the most likely diagnosis in this patient?", "answer": "Coarctation of the aorta", "options": {"A": "Pulmonic stenosis", "B": "Coarctation of the aorta", "C": "Aortic stenosis", "D": "Transposition of great vessels"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old child", "pain", "leg", "playing", "Blood pressure", "upper limb", "90 mm Hg", "lower limbs", "70 mm Hg", "brachiofemoral delay", "pulse", "Auscultation shows", "loud S1", "loud S2", "S4", "presence", "ejection systolic murmur", "area", "Chest X-ray reveals", "notching of", "ribs", "most likely diagnosis", "patient"]}
{"question": "A 59-year-old man comes to the emergency department because of excruciating left knee pain for 4 days. He underwent a total knee arthroplasty of his left knee joint 4 months ago. He has hypertension and osteoarthritis. Current medications include glucosamine, amlodipine, and meloxicam. His temperature is 38.1°C (100.6°F), pulse is 97/min, and blood pressure is 118/71 mm Hg. Examination shows a tender, swollen left knee joint; range of motion is limited by pain. Analysis of the synovial fluid confirms septic arthritis, and the prosthesis is removed. Which of the following is the most likely causal organism?", "answer": "Staphylococcus epidermidis", "options": {"A": "Staphylococcus epidermidis", "B": "Escherichia coli", "C": "Staphylococcus aureus", "D": "Pseudomonas aeruginosa"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old man", "emergency department", "of excruciating left knee pain", "4 days", "total knee arthroplasty", "left", "joint", "months", "hypertension", "osteoarthritis", "Current medications include glucosamine", "amlodipine", "meloxicam", "temperature", "100", "pulse", "97 min", "blood pressure", "71 mm Hg", "Examination shows", "tender", "swollen left knee joint", "range of motion", "limited", "pain", "Analysis", "synovial fluid confirms septic arthritis", "prosthesis", "removed", "following", "most likely causal organism"]}
{"question": "A 47-year-old man presents to the emergency department with fever, fatigue, and loss of appetite for 1 week, followed by right shoulder pain, generalized abdominal pain, and paroxysmal cough. He has had diabetes mellitus for 15 years, for which he takes metformin and gliclazide. His vital signs include a temperature of 38.3°C (101.0°F), pulse of 85/min, and blood pressure of 110/70 mm Hg. On examination, he is ill-appearing, and he has a tender liver edge that is palpable approx. 2 cm below the right costal margin. Percussion and movement worsens the pain. Abdominal ultrasonography is shown. Stool is negative for Entamoeba histolytica antigen. Which of the following is the best initial step in management of this patient condition?", "answer": "Antibiotics and drainage", "options": {"A": "Metronidazole and paromomycin", "B": "Cholecystectomy", "C": "Antibiotics and drainage", "D": "Endoscopic retrograde cholangiopancreatography (ERCP)"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department", "fever", "fatigue", "loss of appetite", "1 week", "followed by right shoulder pain", "generalized abdominal pain", "paroxysmal cough", "diabetes mellitus", "years", "takes metformin", "gliclazide", "vital signs include", "temperature", "3C", "pulse", "85 min", "blood pressure", "70 mm Hg", "examination", "ill appearing", "tender", "palpable", "2 cm", "right costal", "Percussion", "movement worsens", "pain", "Abdominal ultrasonography", "shown", "Stool", "negative", "Entamoeba histolytica antigen", "following", "best initial step", "management", "patient"]}
{"question": "A 36-year-old recent immigrant from India presents with a face similar to that seen in the image A. Examination of his face reveals skin that is thick and contains many lesions. The patient complains that he has experienced a loss of sensation in his toes and fingertips, which has caused him to injure himself often. Biopsy of the skin is likely to reveal bacteria that are:", "answer": "Acid-fast", "options": {"A": "Acid-fast", "B": "Catalase-negative", "C": "Thermophiles", "D": "Tennis-racket shaped"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["36 year old recent immigrant", "India presents", "face similar", "seen", "image", "Examination", "face reveals skin", "thick", "contains", "lesions", "patient", "experienced", "loss of sensation", "toes", "fingertips", "caused", "to", "often", "Biopsy of", "skin", "likely to reveal bacteria"]}
{"question": "A 55-year-old man comes to the physician because of a 3-month history of a progressively growing mass in his axilla. During this period, he has had recurrent episodes of low-grade fever lasting for 7 to 10 days, and an 8-kg (18-lb) weight loss. His only medication is a multivitamin. Physical examination shows nontender, right axillary, cervical, and inguinal lymphadenopathy. His serum calcium concentration is 15.1 mg/dL and parathyroid hormone (PTH) concentration is 9 pg/mL. A lymph node biopsy shows granuloma formation and large CD15-positive, CD30-positive cells with bilobed nuclei. Which of the following is the most likely explanation for this patient's laboratory findings?", "answer": "Secretion of γ-interferon by activated T-lymphocytes", "options": {"A": "Excessive intake of dietary ergocalciferol", "B": "Induction of focal osteolysis by tumor cells", "C": "Secretion of γ-interferon by activated T-lymphocytes", "D": "Production of PTH-related peptide by malignant cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["55 year old man", "physician", "3 month history", "mass", "axilla", "period", "recurrent episodes of low-grade fever", "7", "10 days", "kg", "weight loss", "only medication", "multivitamin", "Physical examination shows nontender", "right axillary", "cervical", "inguinal lymphadenopathy", "serum concentration", "mg/dL", "parathyroid hormone", "concentration", "pg/mL", "lymph node biopsy shows granuloma formation", "large CD15 positive", "CD30-positive cells", "bilobed nuclei", "following", "most likely explanation", "patient's laboratory findings"]}
{"question": "A 32-year-old man comes to the physician for a pre-employment examination. He recently traveled to Guatemala. He feels well but has not seen a physician in several years, and his immunization records are unavailable. Physical examination shows no abnormalities. Serum studies show:\nAnti-HAV IgM Positive\nAnti-HAV IgG Negative\nHBsAg Negative\nAnti-HBs Positive\nHBcAg Negative\nAnti-HBc Negative\nHBeAg Negative\nAnti-HBe Negative\nAnti-HCV Negative\nWhich of the following best explains this patient's laboratory findings?\"", "answer": "Active hepatitis A infection", "options": {"A": "Active hepatitis A infection", "B": "Previous hepatitis A infection", "C": "Chronic hepatitis B infection", "D": "Chronic hepatitis C infection"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "pre employment examination", "recently traveled", "Guatemala", "feels well", "not seen", "physician", "years", "immunization records", "unavailable", "Physical examination shows", "abnormalities", "Serum studies show", "Anti HAV IgM Positive", "Negative HBsAg", "HBs", "HBcAg", "HBc", "HBeAg", "HBe", "HCV Negative", "following best", "patient", "aboratory findings?"]}
{"question": "A 7-month-old male infant is brought to the pediatrician by his mother. She reports that the child develops severe sunburns every time the infant is exposed to sunlight. She has applied copious amounts of sunscreen to the infant but this has not helped the problem. On examination, there are multiple areas of reddened skin primarily in sun exposed areas. The child’s corneas appear irritated and erythematous. Which of the following processes is likely impaired in this patient?", "answer": "Nucleotide excision repair", "options": {"A": "Nucleotide excision repair", "B": "Non-homologous end joining", "C": "Homologous recombination", "D": "Mismatch repair"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old male infant", "brought", "pediatrician", "mother", "reports", "child", "severe sunburns", "time", "infant", "exposed", "sunlight", "applied copious amounts", "sunscreen", "infant", "not helped", "problem", "examination", "multiple areas", "reddened skin", "sun exposed areas", "childs corneas appear", "erythematous", "following processes", "likely impaired", "patient"]}
{"question": "A 65-year-old man presents to his primary care physician with a neck mass. He first noticed a firm mass on the anterior aspect of his neck approximately 4 months ago. The mass is painless and has not increased in size since then. He has also noticed occasional fatigue and has gained 10 pounds in the past 4 months despite no change in his diet or exercise frequency. His past medical history is notable for gout for which he takes allopurinol. He denies any prior thyroid disorder. He runs 4 times per week and eats a balanced diet of mostly fruits and vegetables. He does not smoke and drinks a glass of wine with dinner. His family history is notable for medullary thyroid cancer in his maternal uncle. His temperature is 97.8°F (36.6°C), blood pressure is 127/72 mmHg, pulse is 87/min, and respirations are 19/min. On exam, he has a firm, symmetric, and stone-firm thyroid. A biopsy of this patient's lesion would most likely demonstrate which of the following findings?", "answer": "Dense fibroinflammatory infiltrate", "options": {"A": "Diffuse infiltrate of lymphoid cells destroying thyroid follicles", "B": "Dense fibroinflammatory infiltrate", "C": "Pleomorphic undifferentiated infiltrative cells with necrosis", "D": "Stromal amyloid deposition"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "primary care physician", "neck mass", "first", "firm mass", "anterior aspect of", "neck approximately", "months", "mass", "painless", "not increased in size", "then", "occasional fatigue", "gained 10 pounds", "past", "months", "change in", "diet", "exercise frequency", "past medical history", "notable", "gout", "takes allopurinol", "denies", "prior thyroid disorder", "runs 4 times per week", "eats", "balanced diet", "mostly fruits", "vegetables", "not smoke", "drinks", "glass", "wine", "dinner", "family history", "notable", "medullary thyroid cancer", "maternal uncle", "temperature", "97", "36", "blood pressure", "72 mmHg", "pulse", "87 min", "respirations", "min", "exam", "firm", "symmetric", "stone firm thyroid", "biopsy", "patient's lesion", "most likely", "following findings"]}
{"question": "A group of researchers decided to explore whether the estimates of incidence and prevalence rates of systemic lupus erythematosus (SLE) were influenced by the number of years it took to examine administrative data. These estimates were not only based on hospital discharges, but also on physician billing codes. For study purposes, the researchers labeled incident cases at the initial occurrence of SLE diagnosis in the hospital database, while prevalent cases were those that were coded as harboring SLE at any time, with patients maintaining their diagnosis until death. Which statement is true regarding the relationship between incidence and prevalence rates during the time period that might be chosen for this specific study?", "answer": "Incidence rates will be higher during shorter time periods than longer periods.", "options": {"A": "Incidence rates will be higher during shorter time periods than longer periods.", "B": "The prevalence of SLE during consecutively shorter time windows will be overestimated.", "C": "The inclusion of attack rates would increase incidence estimates in longer time periods.", "D": "The inclusion of attack rates would decrease incidence estimates in shorter time periods."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A group", "researchers", "to", "estimates", "incidence", "prevalence rates", "systemic lupus erythematosus", "influenced", "number", "years", "took to", "administrative data", "estimates", "not only based", "hospital discharges", "physician billing codes", "study purposes", "researchers labeled incident cases", "initial occurrence", "SLE diagnosis", "hospital database", "prevalent cases", "coded", "harboring SLE", "time", "patients maintaining", "diagnosis", "death", "statement", "true", "relationship", "incidence", "prevalence rates", "time period", "chosen", "specific study"]}
{"question": "A 48-year-old Caucasian female presents to her primary care physician for evaluation of progressive weakness and shortness of breath. She has had progressive shortness of breath over the last year with an intermittent non-productive cough. In addition, she complains of difficulty raising her arms to brush her hair. Her temperature is 99.6°F (37.6°C), pulse is 80/min, blood pressure is 130/85 mmHg, respirations are 18/min, and oxygen saturation is 95% on room air. Neurologic exam shows 4/5 strength in the deltoid muscles bilaterally. Diffuse dry crackles are heard on lung auscultation. A faint erythematous rash is noted on the malar cheeks, periorbital areas, lateral proximal thighs, and the elbows. Which of the following tests is most likely to confirm the diagnosis?", "answer": "Muscle biopsy", "options": {"A": "Muscle biopsy", "B": "CT scan", "C": "Serum ANA titer", "D": "Skin biopsy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["48 year old Caucasian female presents", "primary care physician", "evaluation", "progressive weakness", "shortness of breath", "progressive shortness of breath", "last year", "intermittent non-productive cough", "addition", "difficulty", "arms to brush", "hair", "temperature", "99", "pulse", "80 min", "blood pressure", "85 mmHg", "respirations", "min", "oxygen saturation", "95", "room", "Neurologic exam shows 4/5 strength", "deltoid muscles", "Diffuse dry crackles", "heard", "lung auscultation", "faint erythematous rash", "noted", "malar", "periorbital areas", "lateral proximal thighs", "elbows", "following tests", "most likely to confirm", "diagnosis"]}
{"question": "A 46-year-old man presents to the physician with a complaint of a cough for 6 months. He has been taking over-the-counter cough medications, but they have not helped much. He adds that he expectorated bloody sputum the previous night. He denies breathlessness but mentions that he frequently experiences fatigue after little physical exertion. There is no past history of any specific medical disorder. His father died of lung cancer at the age of 54 years. His temperature is 37.0°C (98.6°F), the pulse rate is 82/min, the blood pressure is 118/80 mm Hg, and the respiratory rate is 18/min. Auscultation of his chest reveals the presence of localized rhonchi over the interscapular region. A plain radiograph of the chest shows a coin-like opacity in the right lung. Further diagnostic evaluation confirms the diagnosis of small cell carcinoma of the lung. If his blood were to be sent for laboratory evaluation, which of the following proteins is most likely to be elevated in his serum?", "answer": "Neuron-specific enolase", "options": {"A": "Bence-Jones protein", "B": "Calcitonin", "C": "CA 15-3", "D": "Neuron-specific enolase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "physician", "complaint", "cough", "months", "taking over-the-counter cough medications", "not helped much", "adds", "expectorated bloody sputum", "previous night", "denies breathlessness", "frequently experiences fatigue", "little physical", "past", "specific medical disorder", "father died of lung cancer", "age", "54 years", "temperature", "98", "pulse rate", "min", "blood pressure", "80 mm Hg", "respiratory rate", "min", "Auscultation", "chest reveals", "presence", "localized rhonchi", "interscapular region", "plain radiograph of", "chest shows", "coin", "opacity", "right lung", "Further diagnostic evaluation confirms the diagnosis of small cell carcinoma", "lung", "blood", "to", "sent", "laboratory evaluation", "following proteins", "most likely to", "elevated", "serum"]}
{"question": "A 41-year-old man presents to his primary care provider with abdominal pain. He says that the pain “comes and goes” throughout the day and usually lasts 20-30 minutes per episode. He can point to the spot 1-2 inches above the umbilicus where he feels the pain. He denies any feeling of regurgitation or nighttime cough but endorses nausea. He reports that he used to eat three large meals per day but has found that eating more frequently improves his pain. He tried a couple pills of ibuprofen with food over the past couple days and thinks it helped. He has gained four pounds since his past appointment three months ago. The patient denies any diarrhea or change in his stools. He has no past medical history. He drinks 5-6 beers on the weekend and has a 20 pack-year smoking history. He denies any family history of cancer. On physical exam, he is tender to palpation above the umbilicus. Bowel sounds are present. A stool guaiac test is positive. The patient undergoes endoscopy with biopsy to diagnose his condition.\n\nWhich of the following is most likely to be found on histology?", "answer": "Urease-producing organism in the small intestine", "options": {"A": "Mucosal defect in the stomach", "B": "Urease-producing organism in the small intestine", "C": "PAS-positive material in the small intestine", "D": "Crypt abscesses in the large intestine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care provider", "abdominal pain", "pain", "goes", "day", "usually lasts 20", "episode", "point", "spot", "inches", "umbilicus", "feels", "pain", "denies", "feeling", "regurgitation", "nighttime cough", "nausea", "reports", "used to eat three large meals", "day", "found", "eating", "frequently improves", "pain", "couple pills", "ibuprofen", "food", "past couple days", "thinks", "helped", "gained four pounds", "past appointment three months", "patient denies", "diarrhea", "change in", "stools", "past medical history", "drinks 5-6 beers", "weekend", "20 smoking history", "denies", "family history of cancer", "physical exam", "tender", "palpation", "umbilicus", "Bowel sounds", "present", "stool guaiac test", "positive", "patient", "endoscopy", "biopsy to diagnose", "condition", "following", "most likely to", "found", "histology"]}
{"question": "A 5-year-old female presents to the pediatrician for a routine office visit. The patient is in kindergarten and doing well in school. She is learning to read and is able to write her first name. Her teacher has no concerns. The patient’s mother is concerned that the patient is a picky eater and often returns home from school with most of her packed lunch uneaten. The patient’s past medical history is significant for moderate persistent asthma, which has required three separate week-long courses of prednisone over the last year and recently diagnosed myopia. The patient’s mother is 5’7”, and the patient’s father is 5’10”. The patient’s weight and height are in the 55th and 5th percentile, respectively, which is consistent with her growth curve. On physical exam, the patient has a low hairline and a broad chest. Her lungs are clear with a mild expiratory wheeze. The patient’s abdomen is soft, non-tender, and non-distended. She has Tanner stage I breast development and pubic hair.\n\nThis patient is most likely to have which of the following additional findings?", "answer": "Absent Barr bodies on buccal smear", "options": {"A": "Absent Barr bodies on buccal smear", "B": "Elevated serum alkaline phosphatase level", "C": "Elevated serum TSH level", "D": "Mass in the sella turcica"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["5 year old female presents", "pediatrician", "routine office visit", "patient", "kindergarten", "well", "school", "learning to read", "able to write", "first name", "teacher", "concerns", "patients mother", "concerned", "patient", "picky eater", "often returns home", "school", "most", "packed lunch", "patients past medical history", "significant", "moderate persistent", "required three separate week long courses", "prednisone", "last year", "recently diagnosed myopia", "patients mother", "57", "patients father", "510", "patients weight", "height", "5th percentile", "consistent with", "growth curve", "physical exam", "patient", "low hairline", "broad chest", "lungs", "clear", "mild expiratory wheeze", "patients abdomen", "soft", "non-tender", "non distended", "Tanner breast development", "pubic hair", "patient", "most likely to", "following additional findings"]}
{"question": " A 61-year-old man was started on rosuvastatin 40 mg 8 weeks ago and presents today for a follow-up. He complains of pain in his legs and general weakness. On physical exam, he has full range of motion of his extremities but complains of pain. His blood pressure is 126/84 mm Hg and heart rate is 74/min. The decision is made to stop the statin and return to the clinic in 2 weeks to assess any changes in symptoms. After stopping the statin, his muscular symptoms resolve. What is the next best course of action to take regarding his LDL control?", "answer": "Restart rosuvastatin at a lower dose", "options": {"A": "Restart rosuvastatin at a lower dose", "B": "Initiate fenofibrate", "C": "Initiate a different statin", "D": "Initiate fish oils"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["61 year old man", "started", "rosuvastatin 40 mg", "weeks", "presents today", "follow-up", "pain", "legs", "general weakness", "physical exam", "full range of motion", "extremities", "pain", "blood pressure", "84 mm Hg", "heart rate", "74 min", "decision", "made to stop", "statin", "return", "clinic", "2 weeks to assess", "changes", "symptoms", "stopping", "statin", "muscular symptoms resolve", "next best course", "action to take", "control"]}
{"question": "An unidentified surgical specimen is received for histopathologic analysis. A portion of the specimen is cut and stained with hematoxylin and eosin. The remainder is analyzed and is found to contains type II collagen and chondroitin sulfate. Which of the following structures is most likely the origin of this surgical specimen?", "answer": "Larynx", "options": {"A": "Blood vessel", "B": "Pinna", "C": "Lens", "D": "Larynx"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["unidentified surgical specimen", "received", "histopathologic analysis", "portion", "specimen", "cut", "stained", "hematoxylin", "eosin", "analyzed", "found", "contains type II collagen", "chondroitin sulfate", "following structures", "most likely", "origin", "surgical specimen"]}
{"question": "A 70-year-old woman is brought to the emergency department for the evaluation of abdominal pain, nausea, and vomiting for 1 day. Computed tomography shows a small bowel perforation. The patient is prepared for emergent exploratory laparotomy. She is sedated with midazolam, induced with propofol, intubated, and maintained on nitrous oxide and isoflurane for the duration of the surgery. A single perforation in the terminal ileum is diagnosed intraoperatively and successfully repaired. The patient is transferred to the intensive care unit. The ventilator is set at an FiO2 of 50%, tidal volume of 1000 mL, respiratory rate of 12/min, and positive end-expiratory pressure of 2.5 cm H2O. Her temperature is 37.3°C (99.1°F), pulse is 76/min, and blood pressure is 111/50 mm Hg. She is responsive to painful stimuli. Lung examination shows bilateral rales. Abdominal examination shows a distended abdomen and intact abdominal surgical incisions. The remainder of the physical examination shows no abnormalities. Arterial blood gas analysis shows:\npH 7.44\npO2 54 mm Hg\npCO2 31 mm Hg\nHCO3- 22 mm Hg\nWhich of the following is the best next step in the management of this patient?\"", "answer": "Increase PEEP", "options": {"A": "Increase the FiO2", "B": "Increase the tidal volume", "C": "Increase PEEP", "D": "Increase the respiratory rate"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old woman", "brought", "emergency department", "evaluation", "abdominal", "nausea", "vomiting", "1 day", "Computed tomography shows", "small bowel perforation", "patient", "prepared", "emergent exploratory laparotomy", "sedated", "midazolam", "induced", "propofol", "intubated", "maintained", "nitrous oxide", "isoflurane", "duration", "surgery", "single perforation", "terminal", "diagnosed", "repaired", "patient", "transferred", "intensive care unit", "ventilator", "set", "FiO2", "50", "tidal volume", "mL", "respiratory rate", "min", "positive end-expiratory pressure", "cm H2O", "temperature", "3C", "99", "pulse", "76 min", "blood pressure", "50 mm Hg", "responsive", "painful stimuli", "Lung examination shows bilateral rales", "Abdominal examination shows", "distended abdomen", "intact abdominal surgical incisions", "physical examination shows", "abnormalities", "Arterial blood gas analysis shows", "pH 7", "pO2 54 mm Hg pCO2 31", "HCO3", "following", "best next step", "management", "patient"]}
{"question": "A 43-year-old man with a history of hepatitis C and current intravenous drug use presents with 5 days of fever, chills, headache, and severe back pain. On physical exam, temperature is 100.6 deg F (38.1 deg C), blood pressure is 109/56 mmHg, pulse is 94/min, and respirations are 18/min. He is thin and diaphoretic with pinpoint pupils, poor dentition, and track marks on his arms and legs. A high-pitched systolic murmur is heard, loudest in the left sternal border and with inspiration. He is admitted to the hospital and started on broad-spectrum antibiotics. One of the blood cultures drawn 12 hours ago returns positive for Staphylococcus aureus. Which of the following is the most appropriate next step to confirm the diagnosis?", "answer": "Repeat blood cultures now", "options": {"A": "Repeat blood cultures now", "B": "Repeat blood cultures 24 hours after initial cultures were drawn", "C": "Repeat blood cultures 48 hours after initial cultures were drawn", "D": "Do not repeat blood cultures"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "history of hepatitis C", "current intravenous drug use presents", "5 days", "fever", "chills", "headache", "severe back pain", "physical exam", "temperature", "100", "deg F", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "thin", "diaphoretic", "pinpoint pupils", "poor dentition", "track marks", "arms", "legs", "high-pitched systolic murmur", "heard", "loudest", "left sternal border", "inspiration", "admitted", "hospital", "started", "broad spectrum antibiotics", "One of", "blood cultures drawn 12 hours", "returns positive", "Staphylococcus aureus", "following", "most appropriate next step to confirm", "diagnosis"]}
{"question": "A 42-year-old man with AIDS comes to the physician for intermittent fever, nonproductive cough, malaise, decreased appetite, abdominal pain, and a 3.6-kg (8-lb) weight loss over the past month. He has not seen a doctor since he became uninsured 2 years ago. His temperature is 38.3°C (100.9°F). Abdominal examination shows mild, diffuse tenderness throughout the lower quadrants. The liver is palpated 2–3 cm below the right costal margin, and the spleen is palpated 1–2 cm below the left costal margin. His CD4+ T-lymphocyte count is 49/mm3 (N ≥ 500 mm3). Blood cultures grow acid-fast organisms. A PPD skin test shows 4 mm of induration. Which of the following is the most appropriate pharmacotherapy for this patient's condition?", "answer": "Azithromycin and ethambutol", "options": {"A": "Voriconazole", "B": "Amphotericin B and itraconazole", "C": "Erythromycin", "D": "Azithromycin and ethambutol"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "AIDS", "physician", "intermittent fever", "nonproductive cough", "malaise", "decreased appetite", "abdominal pain", "3.6 kg", "weight loss", "past month", "not seen", "doctor", "uninsured", "years", "temperature", "3C", "100 9F", "Abdominal examination shows mild", "diffuse tenderness", "lower quadrants", "liver", "palpated 23 cm", "right costal margin", "spleen", "palpated", "cm", "left costal margin", "CD4", "lymphocyte count", "mm3", "N", "500 mm3", "Blood cultures", "acid-fast organisms", "PPD skin test shows 4 mm", "induration", "following", "most appropriate pharmacotherapy", "patient's condition"]}
{"question": "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?", "answer": "E2F transcription factors", "options": {"A": "JAK2 tyrosine kinase", "B": "E2F transcription factors", "C": "Phosphoprotein p53", "D": "Cyclin-dependent kinase inhibitors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "scheduled colposcopy", "Two weeks", "routine Pap smear", "showed atypical squamous cells", "Colposcopy shows", "area of white discoloration", "cervix", "application", "acetic acid solution", "Biopsy", "area shows carcinoma-in-situ", "Activation", "following best", "pathogenesis", "condition"]}
{"question": "A research group has developed a low-cost diagnostic retinal imaging device for cytomegalovirus retinitis in a population of HIV-infected patients. In a pilot study of 50 patients, the imaging test detected the presence of CMV retinitis in 50% of the patients. An ophthalmologist slit lamp examination, which was performed for each patient to serve as the gold standard for diagnosis, confirmed a diagnosis of CMV retinitis in 20 patients that were found to be positive through imaging, as well as 1 patient who tested negative with the device. If the prevalence of CMV retinitis in the population decreases due to increased access to antiretroviral therapy, how will positive predictive value and negative predictive value of the diagnostic test be affected?", "answer": "PPV decreases, NPV increases", "options": {"A": "PPV decreases, NPV decreases", "B": "PPV decreases, NPV increases", "C": "PPV increases, NPV decreases", "D": "PPV unchanged, NPV unchanged"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["research group", "low cost diagnostic retinal imaging device", "cytomegalovirus retinitis", "population", "HIV infected patients", "pilot study", "50 patients", "imaging test detected", "presence", "CMV retinitis", "50", "patients", "ophthalmologist slit lamp examination", "performed", "patient to", "gold standard", "diagnosis", "confirmed", "diagnosis", "CMV retinitis", "20 patients", "found to", "positive", "imaging", "1 patient", "tested negative", "device", "prevalence", "CMV retinitis", "population decreases due to increased access", "antiretroviral therapy", "positive predictive value", "negative predictive value of", "diagnostic test", "affected"]}
{"question": "A 35-year-old woman is brought into the clinic by a concerned neighbor who says that the patient is often seen setting up bear traps all around her property because of an impending ‘invasion of the mole people.’ The patient has come to the clinic wearing a garlic necklace. She vaguely explains that the necklace is to mask her scent from the moles tracking her. She has no past psychiatric history and she denies hearing voices or seeing objects. No significant past medical history. Although she has lived in the same community for years, she says she usually keeps to herself and does not have many friends. She holds a regular job at the local hardware store and lives alone. Which of the following is the best initial course of treatment for this patient?", "answer": "Cognitive behavioral therapy (CBT)", "options": {"A": "Cognitive behavioral therapy (CBT)", "B": "The patient does not require any intervention", "C": "Electroconvulsive therapy (ECT)", "D": "Refer to outpatient group therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "brought", "clinic", "neighbor", "patient", "often seen setting up bear traps all", "property", "impending invasion", "mole people", "patient", "clinic", "garlic necklace", "necklace", "to mask", "scent", "moles tracking", "past psychiatric history", "denies hearing voices", "seeing objects", "significant past medical history", "lived", "same community", "years", "usually keeps", "not", "friends", "holds", "regular job", "local hardware store", "lives alone", "following", "best initial course", "treatment", "patient"]}
{"question": "A 71-year-old man complains of urinary hesitancy and nocturia of increasing frequency over the past several months. Digital rectal exam was positive for a slightly enlarged prostate but did not detect any additional abnormalities of the prostate or rectum. The patient’s serum PSA was measured to be 6 ng/mL. Image A shows a transabdominal ultrasound of the patient. Which of the following medications should be included to optimally treat the patient's condition?", "answer": "Finasteride", "options": {"A": "Clonidine", "B": "Finasteride", "C": "Dihydrotestosterone", "D": "Furosemide"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["71 year old man", "urinary hesitancy", "nocturia", "increasing frequency", "past", "months", "Digital rectal exam", "positive", "slightly enlarged prostate", "not detect", "additional abnormalities of the prostate", "rectum", "patients serum PSA", "measured to", "ng/mL", "Image", "shows", "transabdominal ultrasound", "patient", "following medications", "included to", "treat", "patient's condition"]}
{"question": "A 30-year-old man presents to his primary care provider complaining of drowsiness at work for the past several months. He finds his work as a computer programmer rewarding and looks forward to coming into the office every day. However, he often falls asleep during meetings even though he usually gets a good night sleep and has limited his exposure to alcohol and caffeine in the evening. His past medical history is noncontributory. His vital signs are within normal limits. Physical examination is unremarkable. The primary care provider recommends keeping a sleep journal and provides a questionnaire for the patient’s wife. The patient returns one month later to report no changes to his condition. The sleep journal reveals that the patient is getting sufficient sleep and wakes up rested. The questionnaire reveals that the patient does not snore nor does he stop breathing during his sleep. A sleep study reveals mean sleep latency of 6 minutes. Which of the following is the best course of treatment for this patient’s condition?", "answer": "Methylphenidate", "options": {"A": "Methylphenidate", "B": "Sodium oxybate", "C": "Imipramine", "D": "Increase daytime naps"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old man presents", "primary care provider", "drowsiness", "work", "past", "months", "finds", "work", "computer programmer rewarding", "looks forward", "office", "day", "often falls asleep", "meetings", "usually gets", "good night sleep", "limited", "exposure to alcohol", "caffeine", "evening", "past medical history", "vital signs", "normal", "Physical examination", "unremarkable", "primary care provider recommends keeping", "sleep journal", "provides", "questionnaire", "patients wife", "patient returns one month later to report", "changes", "condition", "sleep journal reveals", "patient", "getting sufficient sleep", "wakes up rested", "questionnaire reveals", "patient", "not snore", "stop breathing", "sleep", "sleep study reveals mean sleep latency", "minutes", "following", "best course", "treatment", "patients condition"]}
{"question": "A 40-year-old man comes to the physician for the evaluation of a painless right-sided scrotal swelling. The patient reports that he first noticed the swelling several weeks ago, but it is not always present. He has hypertension treated with enalapril. His father was diagnosed with a seminoma at the age of 25 years. The patient has smoked a pack of cigarettes daily for the past 20 years. Vital signs are within normal limits. Physical examination shows a 10-cm, soft, cystic, nontender right scrotal mass that transilluminates. The mass does not increase in size on coughing and it is possible to palpate normal tissue above the mass. There are no bowel sounds in the mass, and it does not reduce when the patient is in a supine position. Examination of the testis shows no abnormalities. Which of the following is the most likely cause of the mass?", "answer": "Imbalance of fluid secretion and resorption by the tunica vaginalis", "options": {"A": "Patent processus vaginalis", "B": "Dilation of the pampiniform plexus", "C": "Twisting of the spermatic cord", "D": "Imbalance of fluid secretion and resorption by the tunica vaginalis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["40 year old man", "physician", "evaluation of", "painless right-sided scrotal swelling", "patient reports", "first", "swelling", "weeks", "not always present", "hypertension treated with enalapril", "father", "diagnosed", "seminoma", "age", "years", "patient", "smoked", "pack", "cigarettes daily", "past 20 years", "Vital signs", "normal", "Physical examination shows a 10", "soft", "cystic", "nontender right scrotal mass", "mass", "not increase in size", "coughing", "possible to palpate normal tissue", "mass", "bowel", "mass", "not", "patient", "supine position", "Examination of", "testis shows", "abnormalities", "following", "most likely cause", "mass"]}
{"question": "A 62-year-old man presents to the physician because of incomplete healing of a chest wound. He recently had a triple coronary artery bypass graft 3 weeks ago. His past medical history is significant for type 2 diabetes mellitus and hypertension for the past 25 years. Clinical examination shows the presence of wound dehiscence in the lower 3rd of the sternal region. The wound surface shows the presence of dead necrotic tissue with pus. Computed tomography (CT) of the thorax shows a small fluid collection with fat stranding in the perisurgical soft tissues. What is the most appropriate next step in the management of the patient?", "answer": "Surgical debridement", "options": {"A": "Surgical debridement", "B": "Negative pressure wound management", "C": "Sternal wiring", "D": "Sternal fixation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man presents", "physician", "incomplete healing", "chest", "recently", "triple coronary artery bypass graft", "weeks", "past medical history", "significant", "type 2 diabetes mellitus", "hypertension", "past", "years", "Clinical examination shows", "presence of wound dehiscence", "lower 3rd", "sternal region", "wound surface shows", "presence", "dead necrotic tissue", "pus", "Computed tomography", "thorax shows", "small fluid collection", "fat stranding", "soft tissues", "most appropriate next step", "management", "patient"]}
{"question": "The Kozak sequence for the Beta-globin gene has a known mutation which decreases, though does not abolish, translation of the Beta-globin mRNA, leading to a phenotype of thalassemia intermedia. What would the blood smear be expected to show in a patient positive for this mutation?", "answer": "Microcytic red blood cells", "options": {"A": "Macrocytic red blood cells", "B": "Hyperchromic red blood cells", "C": "Microcytic red blood cells", "D": "Bite cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["sequence", "Beta", "known mutation", "decreases", "not", "translation", "Beta-globin mRNA", "leading", "phenotype", "thalassemia intermedia", "blood smear", "expected to show", "patient positive", "mutation"]}
{"question": "A 68-year-old man from California presents for a routine checkup. He does not have any complaints. He says that he has tried to keep himself healthy and active by jogging and gardening since his retirement at age 50. He adds that he spends his mornings in the park and his afternoons in his garden. He has no significant medical history. The patient denies any smoking history and drinks alcohol occasionally. On physical examination, the following lesion is seen on his scalp (see image). Which of the following is the most likely diagnosis?", "answer": "Actinic keratosis", "options": {"A": "Psoriasis", "B": "Seborrheic keratosis", "C": "Actinic keratosis", "D": "Squamous cell carcinoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["68 year old man", "California presents", "routine checkup", "not", "complaints", "to keep", "healthy", "active", "jogging", "gardening", "retirement", "age 50", "adds", "spends", "mornings", "park", "afternoons", "garden", "significant medical history", "patient denies", "smoking history", "drinks alcohol occasionally", "physical examination", "following lesion", "seen", "scalp", "see image", "following", "most likely diagnosis"]}
{"question": "A routine newborn screening test for phenylketonuria in a male neonate shows a serum phenylalanine concentration of 44 mg/dL (N < 20). He is started on a special diet and the hyperphenylalaninemia resolves. At a routine well-child examination 4 months later, the physician notices that he has persistent head lag. On examination, he has blue eyes, pale skin, blonde hair, and generalized hypotonia. His serum prolactin level is markedly elevated. Supplementation of which of the following substances is most likely to prevent further complications of this patient's condition?", "answer": "Tetrahydrobiopterin", "options": {"A": "Tyrosine", "B": "Pyridoxine", "C": "Thiamine", "D": "Tetrahydrobiopterin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["routine newborn screening test for phenylketonuria", "male neonate shows", "serum phenylalanine concentration", "mg/dL", "N", "20", "started", "special diet", "hyperphenylalaninemia resolves", "routine well child examination 4 months later", "physician", "persistent head lag", "examination", "blue eyes", "pale skin", "blonde hair", "generalized hypotonia", "serum prolactin level", "markedly elevated", "Supplementation", "following substances", "most likely to prevent further complications", "patient's condition"]}
{"question": "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?", "answer": "Decreased ALA synthesis", "options": {"A": "Inhibition of ferrochelatase", "B": "Increased homocysteine degradation", "C": "Increased GABA production", "D": "Decreased ALA synthesis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old nursing presents", "clinic", "complaints", "breathlessness", "cough", "night sweats", "past 2 months", "further", "concerns", "possibility", "contracting tuberculosis", "one", "patients", "care", "treated", "tuberculosis", "PPD skin test", "reads", "mm", "day 3", "Chest X-ray demonstrates", "lesion", "right upper lobe", "standard", "tuberculosis medication regimen", "started", "follow-up appointment", "months later", "patient presents", "fatigue", "experiencing occasional dizziness", "weakness", "numbness in", "feet", "Physical exam", "positive", "conjunctival pallor", "Lab work", "significant", "a hemoglobin level", "10 g/dL", "mean corpuscular volume", "68 fl", "most likely cause", "current symptoms"]}
{"question": "A 23-year-old woman is referred to a genetic counselor. She is feeling well but is concerned because her brother was recently diagnosed with hereditary hemochromatosis. All first-degree relatives were encouraged to undergo genetic screening for any mutations associated with the disease. Today, she denies fever, chills, joint pain, or skin hyperpigmentation. Her temperature is 37.0°C (98.6°F), pulse is 85/min, respirations are 16/min, and blood pressure is 123/78 mm Hg. Her physical examination is normal. Her serum iron, hemoglobin, ferritin, and AST and ALT concentrations are normal. Gene screening will involve a blood specimen. Which of the following genes would suggest hereditary hemochromatosis?", "answer": "HFE gene", "options": {"A": "BCR-ABL gene", "B": "BRCA gene", "C": "FA gene", "D": "HFE gene"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["23 year old woman", "referred to", "genetic counselor", "feeling well", "concerned", "brother", "recently diagnosed", "hereditary hemochromatosis", "first-degree relatives", "to", "genetic", "mutations associated with", "disease", "Today", "denies fever", "chills", "joint pain", "skin hyperpigmentation", "temperature", "98", "pulse", "85 min", "respirations", "min", "blood pressure", "mm Hg", "physical examination", "normal", "serum iron", "hemoglobin", "ferritin", "AST", "ALT concentrations", "normal", "Gene screening", "blood specimen", "following genes", "suggest hereditary hemochromatosis"]}
{"question": "A 16-year-old girl is brought to the emergency department with constant abdominal pain over the past 8 hours. The pain is in her right lower quadrant (RLQ), which is also where it began. She has had no nausea or vomiting despite eating a snack 2 hours ago. She had a similar episode last month which resolved on its own. Her menstrual cycles are 28–30 days apart with 3–5 days of vaginal bleeding. Her last menses ended 9 days ago. Her blood pressure is 125/75 mm Hg, the pulse is 78/min, the respirations are 15/min, and the temperature is 37.2°C (99.0°F). Abdominal examination shows moderate pain on direct pressure over the RLQ which decreases with the release of pressure. The remainder of the physical examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.5 mg/dL\nLeukocyte count 6000/mm3\nSegmented neutrophils 55%\nLymphocytes 39%\nPlatelet count 260,000/mm3\nSerum  \nC-reactive protein 5 mg/L (N < 8 mg/L)\nUrine  \nRBC 1-2 phf\nWBC None\nWhich of the following is the most appropriate next step in management?", "answer": "Reassurance", "options": {"A": "Methotrexate", "B": "Nitrofurantoin", "C": "Reassurance", "D": "Referral for surgery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "emergency department", "constant abdominal", "past 8 hours", "pain", "right lower quadrant", "began", "nausea", "vomiting", "eating", "snack", "hours", "similar episode", "month", "resolved", "menstrual cycles", "days", "35", "vaginal bleeding", "last menses ended", "days", "blood pressure", "75 mm Hg", "pulse", "min", "respirations", "min", "temperature", "99", "Abdominal examination shows moderate pain", "direct pressure", "RLQ", "decreases", "release", "pressure", "physical examination shows", "abnormalities", "Laboratory studies show", "Hemoglobin 12.5 mg/dL Leukocyte", "neutrophils", "Lymphocytes", "Platelet", "C-reactive protein", "L", "N", "mg/L", "Urine", "RBC", "phf WBC", "following", "most appropriate next step", "management"]}
{"question": "A 30-year-old male presents to the emergency department with a complaint of abdominal pain. The patient states he was at a barbecue around noon. Lunch was arranged as a buffet without refrigeration. Within 2 to 3 hours, he had abdominal pain with 3 episodes of watery diarrhea. On exam, vital signs are T 99.1, HR 103, BP 110/55, RR 14. Abdominal exam is significant for pain to deep palpation without any rebounding or guarding. There is no blood on fecal occult testing (FOBT). What is the most likely cause of this patient's presentation?", "answer": "Staphylococcus aureus", "options": {"A": "Salmonella enteritidis", "B": "Listeria monocytogenes", "C": "Staphylococcus aureus", "D": "Vibrio cholerae"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old male presents", "emergency department", "complaint", "abdominal pain", "patient states", "noon", "Lunch", "arranged", "refrigeration", "2", "hours", "abdominal pain", "episodes of watery diarrhea", "exam", "vital signs", "T 99", "BP", "55", "RR", "Abdominal exam", "significant", "pain", "deep palpation", "guarding", "blood", "fecal occult testing", "most likely cause", "patient's presentation"]}
{"question": "A 70-year-old man is brought to the emergency department by staff of the group home where he resides because of worsening confusion for the past week. He has a history of major depressive disorder and had an ischemic stroke 4 months ago. Current medications are aspirin and sertraline. He is lethargic and disoriented. His pulse is 78/min, and blood pressure is 135/88 mm Hg. Physical examination shows moist oral mucosa, normal skin turgor, and no peripheral edema. While in the waiting room, he has a generalized, tonic-clonic seizure. Laboratory studies show a serum sodium of 119 mEq/L and an elevated serum antidiuretic hormone concentration. Which of the following sets of additional laboratory findings is most likely in this patient?\n $$$ Serum osmolality %%% Urine sodium %%% Serum aldosterone $$$", "answer": "↓ ↑ ↓", "options": {"A": "↓ ↓ ↓", "B": "↑ ↓ normal", "C": "↓ ↑ ↑", "D": "↓ ↑ ↓"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man", "brought", "emergency department", "staff", "group home", "resides", "worsening confusion", "past week", "history of major depressive disorder", "ischemic stroke", "months", "Current medications", "aspirin", "sertraline", "lethargic", "disoriented", "pulse", "min", "blood pressure", "88 mm Hg", "Physical examination shows moist oral mucosa", "normal", "peripheral edema", "waiting room", "generalized", "tonic-clonic seizure", "Laboratory studies show", "serum sodium", "mEq/L", "elevated serum antidiuretic hormone concentration", "following sets", "additional laboratory findings", "most likely", "patient", "Serum", "Urine", "aldosterone"]}
{"question": "A 35-year-old woman presents with severe fear reactions to seeing dogs after moving into a new suburban neighborhood. She states that she has always had an irrational and excessive fear of dogs but has been able to avoid it for most of her life while living in the city. When she sees her neighbors walking their dogs outside, she is terrified and begins to feel short of breath. Recently, she has stopped picking up her children from the bus stop and no longer plays outside with her children in order to avoid seeing any dogs. Which of the following would be the best definitive treatment for this patient?", "answer": "Systematic desensitization", "options": {"A": "Selective serotonin reuptake inhibitors (SSRIs)", "B": "Short-acting benzodiazepines", "C": "Systematic desensitization", "D": "Cognitive behavioral therapy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old woman presents", "severe fear reactions", "seeing dogs", "moving", "new suburban neighborhood", "states", "always", "irrational", "excessive fear", "dogs", "able to", "most", "life", "living", "city", "sees", "neighbors walking", "dogs outside", "terrified", "begins to feel short of breath", "Recently", "stopped picking", "children", "bus stop", "longer plays outside", "children", "order to", "seeing", "dogs", "following", "best definitive", "patient"]}
{"question": "A 45-year-old man arrives by ambulance to the emergency room after being involved in a very severe construction accident. The patient was found unconscious with a large metal spike protruding from his abdomen by a coworker who was unable to estimate the amount of time the patient went without medical aid. Upon arrival to the ER, the patient was unconscious and unresponsive. His vital signs are BP: 80/40, HR: 120 bpm, RR: 25 bpm, Temperature: 97.1 degrees, and SPO2: 99%.He is taken to the operating room to remove the foreign body and control the bleeding. Although both objectives were accomplished, the patient had an acute drop in his blood pressure during the surgery at which time ST elevations were noted in multiple leads. This resolved with adequate fluid resuscitation and numerous blood transfusions. The patient remained sedated after surgery and continued to have relatively stable vital signs until his third day in the intensive care unit, when he experiences an oxygen desaturation of 85% despite being on a respirator with 100% oxygen at 15 breaths/minute. On auscultation air entry is present bilaterally with the presence of crackles. A 2/6 systolic murmur is heard. Readings from a Swan-Ganz catheter display the following: central venous pressure (CVP): 4 mmHg, right ventricular pressure (RVP) 20/5 mmHg, pulmonary artery pressure (PAP): 20/5 mmHg. Pulmonary capillary wedge pressure (PCWP): 5 mm Hg. A chest x-ray is shown as Image A. The patient dies soon after this episode. What is the most likely direct cause of his death?", "answer": "Diffuse alveolar damage", "options": {"A": "Diffuse alveolar damage", "B": "Ventricular septal defect", "C": "Myocardial free wall rupture", "D": "Myocardial reinfarction"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "ambulance", "emergency room", "involved", "very severe construction accident", "patient", "found unconscious", "large metal", "protruding", "abdomen", "coworker", "unable to estimate", "amount", "time", "patient", "medical aid", "arrival", "ER", "patient", "unconscious", "unresponsive", "vital signs", "BP", "80 40", "Temperature", "97", "degrees", "99", "taken", "operating room to remove", "foreign body", "control", "bleeding", "objectives", "patient", "acute drop in", "blood pressure", "surgery", "time ST elevations", "noted", "multiple leads", "resolved", "adequate fluid resuscitation", "numerous blood transfusions", "patient", "sedated", "surgery", "continued to", "stable vital signs", "third day", "intensive care unit", "experiences", "oxygen desaturation", "85", "respirator", "100", "oxygen", "15 breaths/minute", "auscultation air entry", "present", "presence", "crackles", "2/6 systolic murmur", "heard", "Readings", "Swan-Ganz catheter display", "following", "central venous pressure", "4 mmHg", "right ventricular pressure", "20", "mmHg", "pulmonary artery pressure", "PAP", "20", "mmHg", "Pulmonary capillary wedge pressure", "5 mm Hg", "chest x-ray", "shown", "Image", "patient dies", "episode", "most likely direct cause of", "death"]}
{"question": "A 76-year-old man with chronic obstructive pulmonary disease (COPD) presents complaining of 3 weeks of cough and progressive dyspnea on exertion in the setting of a 20 pound weight loss. He is a 60 pack-year smoker, worked as a shipbuilder 30 years ago, and recently traveled to Ohio to visit family. Chest radiograph shows increased bronchovascular markings, reticular parenchymal opacities, and multiple pleural plaques. Labs are unremarkable except for a slight anemia. Which of the following is the most likely finding on this patient's chest CT?", "answer": "Lower lobe cavitary mass", "options": {"A": "Nodular mass spreading along pleural surfaces", "B": "Honeycombing", "C": "Air bronchogram", "D": "Lower lobe cavitary mass"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["76 year old man", "chronic obstructive pulmonary disease", "presents complaining of", "weeks", "cough", "progressive dyspnea on exertion", "setting", "20 pound weight loss", "60 pack-year smoker", "worked", "30 years", "recently traveled", "Ohio to visit family", "Chest radiograph shows increased", "markings", "reticular parenchymal opacities", "multiple pleural plaques", "Labs", "unremarkable", "slight anemia", "following", "most likely finding", "patient's chest CT"]}
{"question": "A 60-year-old man presents with a 2-day history of increasing difficulty in breathing with a productive cough. He reports having shortness of breath over the last 6 months, but he has felt worse since he contracted a cold that has been traveling around his office. Today, he reports body aches, headache, and fever along with this chronic cough. His past medical history is significant for prediabetes, which he controls with exercise and diet. He has a 30-pack-year smoking history. His blood pressure is 130/85 mmHg, pulse rate is 90/min, temperature is 36.9°C (98.5°F), and respiratory rate is 18/min. Physical examination reveals diminished breath sounds bilateral, a barrel-shaped chest, and measured breathing through pursed lips. A chest X-ray reveals a flattened diaphragm and no signs of consolidation. Pulmonary function testing reveals FEV1/FVC ratio of 60%. Arterial blood gases (ABG) of this patient are most likely to reveal which of the following?", "answer": "Primary respiratory acidosis", "options": {"A": "Primary respiratory acidosis", "B": "Primary respiratory alkalosis", "C": "Compensatory respiratory acidosis", "D": "Anion gap metabolic acidosis with respiratory alkalosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["60 year old man presents", "2-day history", "increasing difficulty", "breathing", "productive cough", "reports", "shortness of breath", "last", "months", "felt worse", "contracted", "cold", "traveling", "office", "Today", "reports body aches", "headache", "fever", "with", "chronic cough", "past medical history", "significant", "prediabetes", "controls", "exercise", "diet", "30 pack-year smoking history", "blood pressure", "85 mmHg", "pulse rate", "90 min", "temperature", "36", "98", "respiratory rate", "min", "Physical examination reveals diminished breath sounds bilateral", "barrel-shaped chest", "measured breathing", "pursed lips", "chest X-ray reveals", "flattened diaphragm", "signs", "consolidation", "Pulmonary function testing reveals FEV1/FVC ratio", "60", "Arterial blood gases", "patient", "most likely to reveal", "following"]}
{"question": "A 34-year-old male suffers from inherited hemophilia A. He and his wife have three unaffected daughters. What is the probability that the second daughter is a carrier of the disease?", "answer": "100%", "options": {"A": "0%", "B": "25%", "C": "50%", "D": "100%"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male suffers", "inherited hemophilia A", "wife", "three unaffected daughters", "probability", "second daughter", "carrier of", "disease"]}
{"question": "A 76-year-old man is brought to his physician's office by his wife due to progressively worsening hearing loss. The patient reports that he noticed a decrease in his hearing approximately 10 years ago. His wife says that he watches television at an elevated volume and appears to have trouble understanding what is being said to him, especially when there is background noise. He states that he also experiences constant ear ringing and episodes of unsteadiness. On physical examination, the outer ears are normal and otoscopic findings are unremarkable. The patient is unable to repeat the sentence said to him on whisper testing. When a vibrating tuning fork is placed in the middle of the patient's forehead, it is heard equally on both ears. When the vibrating tuning fork is placed by the ear and then on the mastoid process, air conduction is greater than bone conduction. Which of the following structures is most likely impaired in this patient?", "answer": "Cochlea", "options": {"A": "Tympanic membrane", "B": "Malleus", "C": "Incus", "D": "Cochlea"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["76 year old man", "brought", "physician's office", "wife due to", "worsening hearing loss", "patient reports", "decrease", "hearing approximately 10 years", "wife", "television", "elevated volume", "appears to", "understanding", "background noise", "states", "experiences constant ear ringing", "episodes of unsteadiness", "physical examination", "outer ears", "normal", "otoscopic findings", "unremarkable", "patient", "unable to repeat", "sentence", "testing", "tuning fork", "placed", "middle", "patient's forehead", "heard", "ears", "tuning fork", "placed", "ear", "then", "mastoid process", "air conduction", "greater than bone conduction", "following structures", "most likely impaired", "patient"]}
{"question": "A 13-year-old boy is brought to the emergency department by his mother because of a 6-hour history of severe eye pain and blurry vision. He wears soft contact lenses and has not removed them for 2 days. Ophthalmologic examination shows a deep corneal ulcer, severe conjunctival injection, and purulent discharge on the right. Treatment with topical ciprofloxacin is initiated. A culture of the ocular discharge is most likely to show which of the following?", "answer": "Gram-negative, oxidase-positive bacilli", "options": {"A": "Gram-negative, non-maltose fermenting diplococci", "B": "Gram-negative, lactose-fermenting bacilli", "C": "Gram-negative, oxidase-positive bacilli", "D": "Gram-positive, optochin-sensitive diplococci\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "emergency department", "mother", "hour history", "severe eye pain", "blurry vision", "soft contact lenses", "not removed", "2 days", "Ophthalmologic examination shows", "deep corneal ulcer", "severe conjunctival injection", "purulent discharge", "right", "Treatment", "topical ciprofloxacin", "initiated", "culture", "ocular discharge", "most likely to show", "following"]}
{"question": "A 31-year-old female patient complains of numbness and tingling in her left hand, weakness, difficulty with walking, dizziness, and bladder dysfunction. She said that about a year ago, she had trouble with her vision, and that it eventually recovered in a few days. On physical exam, bilateral internuclear ophthalmoplegia, hyperreflexia in both patella, and bilateral clonus, are noted. A magnetic resonance imaging (MRI) study was done (Figure 1). If a lumbar puncture is performed in this patient, which of the following would most likely be found in cerebrospinal fluid analysis?", "answer": "Oligoclonal IgG bands on electrophoresis", "options": {"A": "Presence of 14-3-3 protein", "B": "Decreased glucose with neutrophilic predominance", "C": "Oligoclonal IgG bands on electrophoresis", "D": "Decreased IgG CSF concentration"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["31 year old female patient", "numbness", "tingling", "left hand", "weakness", "difficulty", "walking", "dizziness", "bladder dysfunction", "year", "vision", "recovered", "days", "physical exam", "bilateral internuclear ophthalmoplegia", "hyperreflexia", "patella", "bilateral clonus", "noted", "magnetic resonance", "study", "lumbar puncture", "performed", "patient", "following", "most likely", "found", "cerebrospinal fluid analysis"]}
{"question": "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:\nFasting glucose 97 mg/L\nALT 12 IU/L\nAST 14 IU/L\nTotal bilirubin 0.8 mg/dL(15 µmol/L)\nPlasma creatinine 0.7 mg/dL (61.9 µmol/L)\nWhich of the following tests are indicated to determine the cause of the abnormal dipstick test results?", "answer": "No tests required", "options": {"A": "HbA1c measurement", "B": "No tests required", "C": "Urinalysis", "D": "Oral glucose tolerance test"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old primigravida presents", "regular prenatal visit", "weeks gestation", "concerned", "results", "dipstick test", "performed at home", "showed 1", "glucose", "not", "liquid consumption", "increased", "more frequently", "course", "pregnancy", "unremarkable", "significant co-morbidities", "BMI", "kg/cm2", "gained 3 kg", "72", "pregnancy", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "lungs", "clear", "auscultation", "heart sounds", "normal", "murmurs", "abdominal", "costovertebral angle tenderness", "laboratory tests show", "following results", "Fasting glucose 97 mg/L ALT 12 IU", "AST", "Total bilirubin 0 8 mg dL", "mol/L", "Plasma creatinine 0.7 mg/dL", "61", "mol/L", "following tests", "indicated to", "cause", "abnormal dipstick"]}
{"question": "A 9-month-old boy is brought to the physician by his mother because of intermittent watery diarrhea for several months. Pregnancy and delivery were uncomplicated. He was diagnosed with eczematous dermatitis at 3 months old. His height and weight are below the 5th percentile. Immunologic evaluation shows a defect in activated regulatory T cells. A genetic analysis shows a mutation in the FOXP3 gene. This patient is at increased risk for which of the following?", "answer": "Autoimmune endocrinopathy", "options": {"A": "Hemorrhagic diathesis", "B": "Ocular telangiectasias", "C": "Autoimmune endocrinopathy", "D": "Retained primary teeth"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "physician", "mother", "intermittent watery", "several months", "Pregnancy", "delivery", "uncomplicated", "diagnosed", "eczematous dermatitis", "3 months old", "height", "weight", "5th percentile", "Immunologic evaluation shows", "defect", "activated regulatory T cells", "genetic analysis shows", "mutation", "FOXP3", "patient", "increased risk", "following"]}
{"question": "A 57-year-old man comes to the physician because of a 3-week history of abdominal bloating and increased frequency of stools. He describes the stools as bulky, foul-smelling, and difficult to flush. He also has a 4-month history of recurrent dull upper abdominal pain that usually lasts for a few days, worsens after meals, and is not relieved with antacids. He has had a 10-kg (22-lb) weight loss in the past 4 months. He has no personal or family history of serious illness. He has smoked 1 pack of cigarettes daily for 37 years. He has a 12-year history of drinking 6 to 8 beers daily. He is 160 cm (5 ft 3 in) tall and weighs 52 kg (115 lb); BMI is 20 kg/m2. His vital signs are within normal limits. Abdominal examination shows mild epigastric tenderness without rebound or guarding. Bowel sounds are normal. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in diagnosis?", "answer": "Abdominal CT scan", "options": {"A": "Abdominal CT scan", "B": "Endoscopic ultrasonography", "C": "Abdominal ultrasound", "D": "Upper gastrointestinal endoscopy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["57 year old man", "physician", "3 week history", "abdominal bloating", "increased frequency of stools", "stools", "bulky", "foul-smelling", "difficult to flush", "4 month history", "recurrent dull upper", "usually", "days", "worsens", "meals", "not relieved with antacids", "a 10 kg", "weight loss", "past", "months", "personal", "family history", "serious illness", "smoked 1 pack", "cigarettes daily", "years", "12 year history", "drinking 6", "beers daily", "5 ft", "tall", "kg", "BMI", "20 kg/m2", "vital signs", "normal limits", "Abdominal examination shows mild epigastric tenderness", "guarding", "Bowel sounds", "normal", "examination shows", "abnormalities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 67-year-old white man presents to his primary care provider for an annual examination. He notes a pink bump that has rapidly developed on his forehead over the last month. In the past, he has had significant sun exposure including multiple blistering sunburns. The physical examination reveals a 2 cm dome-shaped plaque with a central keratin plug (as shown in the image). Excisional biopsy of the lesion reveals an exophytic nodule with central invagination, full of keratin. Keratinocyte atypia is minimal. Which of the following is the most likely diagnosis?", "answer": "Keratoacanthoma", "options": {"A": "Keratoacanthoma", "B": "Basal cell carcinoma", "C": "Seborrheic keratosis", "D": "Kaposi's sarcoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old white man presents", "primary care provider", "annual examination", "notes", "pink", "rapidly", "forehead", "last month", "past", "significant sun exposure including multiple blistering sunburns", "physical examination reveals", "2", "dome-shaped plaque", "central keratin", "shown", "image", "Excisional", "lesion reveals", "exophytic nodule", "central invagination", "full", "keratin", "Keratinocyte atypia", "minimal", "following", "most likely diagnosis"]}
{"question": "A 56-year-old man presents to his primary care doctor with intermittent chest pain. He reports a 2-month history of exertional chest pain that commonly arises after walking 5 or more blocks. He describes the pain as dull, burning, non-radiating substernal pain. His past medical history is notable for hypercholesterolemia and hypertension. He takes simvastatin and losartan. His temperature is 98.9°F (37.2°C), blood pressure is 150/85 mmHg, pulse is 88/min, and respirations are 18/min. On exam, he is well-appearing and in no acute distress. S1 and S2 are normal. No murmurs are noted. An exercise stress test is performed to further evaluate the patient’s pain. Which of the following substances is released locally to increase coronary blood flow during exertion?", "answer": "Adenosine", "options": {"A": "Adenosine", "B": "Inorganic phosphate", "C": "Prostaglandin E2", "D": "Transforming growth factor beta"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care doctor", "intermittent chest", "reports", "2 month history of exertional chest pain", "walking", "more blocks", "pain", "dull", "burning", "non radiating substernal pain", "past medical history", "notable", "hypercholesterolemia", "hypertension", "takes simvastatin", "losartan", "temperature", "98 9F", "blood pressure", "85 mmHg", "pulse", "88 min", "respirations", "min", "exam", "well appearing", "acute distress", "S1", "S2", "normal", "murmurs", "noted", "exercise stress test", "performed to further evaluate", "patients pain", "following substances", "released locally to increase coronary blood", "exertion"]}
{"question": "A 69-year-old male with a history of metastatic small cell lung carcinoma on chemotherapy presents to his oncologist for a follow-up visit. He has responded well to etoposide and cisplatin with plans to undergo radiation therapy. However, he reports that he recently developed multiple “spots” all over his body. He denies any overt bleeding from his gums or joint swelling. His past medical history is notable for iron deficiency anemia, osteoarthritis, and paraneoplastic Lambert-Eaton syndrome. He has a 40 pack-year smoking history. His temperature is 98.5°F (36.9°C), blood pressure is 130/70 mmHg, pulse is 115/min, and respirations are 20/min. On examination, a rash is noted diffusely across the patient’s trunk and bilateral upper and lower extremities.\n\nResults from a complete blood count are shown below:\nHemoglobin: 11.9 mg/dl\nHematocrit: 35%\nLeukocyte count: 5,000/mm^3\nPlatelet count: 20,000/mm^3\n\nThe oncologist would like to continue chemotherapy but is concerned that the above results will limit the optimal dose and frequency of the regimen. A recombinant version of which of the following is most appropriate in this patient?", "answer": "Interleukin 11", "options": {"A": "Interleukin 2", "B": "Interleukin 8", "C": "Interleukin 11", "D": "Granulocyte colony stimulating factor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["male", "history of metastatic small cell lung carcinoma", "chemotherapy presents", "oncologist", "follow-up visit", "well", "etoposide", "cisplatin", "plans to", "radiation therapy", "reports", "recently", "multiple spots", "body", "denies", "bleeding", "gums", "joint swelling", "past medical history", "notable", "iron deficiency anemia", "osteoarthritis", "paraneoplastic Lambert-Eaton syndrome", "40 pack-year smoking history", "temperature", "98", "36", "blood pressure", "70 mmHg", "pulse", "min", "respirations", "20 min", "examination", "rash", "noted", "patients trunk", "bilateral upper", "lower extremities", "Results", "complete blood count", "shown", "Hemoglobin", "9 mg dl Hematocrit", "35", "Leukocyte count", "5", "mm", "Platelet count", "20", "mm", "oncologist", "to continue chemotherapy", "concerned", "above results", "limit", "optimal dose", "frequency", "regimen", "recombinant version", "following", "most appropriate", "patient"]}
{"question": "A 60-year-old man with a history of osteoarthritis has been awaiting hip replacement surgery for 3 years. During his annual physical, he reports that he has been taking over the counter pain medications, but that no amount of analgesics can relieve his constant pain. Laboratory results reveal that his renal function has deteriorated when compared to his last office visit 2 years ago. Serum creatinine is 2.0 mg/dL, and urinalysis shows 1+ proteinuria. There are no abnormalities seen on microscopy of the urine. A renal biopsy shows eosinophilic infiltration and diffuse parenchymal inflammation. What is the most likely explanation for this patient's deterioration in renal function?", "answer": "Toxic tubulointerstitial nephritis", "options": {"A": "Focal segmental glomerulosclerosis", "B": "Ischemic acute tubular necrosis", "C": "Nephrotoxic acute tubular necrosis", "D": "Toxic tubulointerstitial nephritis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old man", "history of osteoarthritis", "hip replacement surgery", "3 years", "annual physical", "reports", "taking over the counter pain medications", "amount", "analgesics", "relieve", "constant pain", "Laboratory results reveal", "renal function", "deteriorated", "compared", "office visit", "years", "Serum creatinine", "2 0 mg/dL", "urinalysis shows 1", "proteinuria", "abnormalities seen", "microscopy", "urine", "renal biopsy shows eosinophilic infiltration", "diffuse parenchymal inflammation", "most likely explanation", "patient's deterioration", "renal function"]}
{"question": "A 62-year-old man presents to the emergency department with shortness of breath. The patient says he feels as if he is unable to take a deep breath. The patient has a past medical history of COPD and a 44-pack-year smoking history. The patient has been admitted before for a similar presentation. His temperature is 98.7°F (37.1°C), blood pressure is 177/118 mmHg, pulse is 123/min, respirations are 33/min, and oxygen saturation is 80% on room air. The patient is started on 100% oxygen, albuterol, ipratropium, magnesium, and prednisone. The patient claims he is still short of breath. Physical exam reveals bilateral wheezes and poor air movement. His oxygen saturation is 80%. Which of the following is the best next step in management?", "answer": "BiPAP", "options": {"A": "BiPAP", "B": "Chest tube placement", "C": "Intubation", "D": "Needle decompression"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man presents", "emergency department", "shortness of breath", "patient", "feels", "unable to take", "deep breath", "patient", "past medical COPD", "pack-year smoking history", "patient", "admitted before", "similar presentation", "temperature", "98", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "80", "room air", "patient", "started", "100", "oxygen", "albuterol", "ipratropium", "magnesium", "prednisone", "patient", "short of breath", "Physical exam reveals bilateral wheezes", "poor air movement", "oxygen saturation", "80", "following", "best next step", "management"]}
{"question": "A 76-year-old man is brought to the physician by his wife because of low back pain and weakness for the past 4 weeks. He says that the pain is sharp, radiates to his left side, and has a burning quality. He has had a cough occasionally productive of blood-streaked sputum for the past 2 months. He has had 3.2-kg (7.0-lb) weight loss in that time. He is now unable to walk without assistance and has had constipation and difficulty urinating for the past 2 weeks. He has hypertension treated with enalapril. He has smoked 1 pack of cigarettes daily for 60 years. His temperature is 37°C (98.6°F), pulse is 75/min, and blood pressure is 150/80 mm Hg. He is oriented to person, place, and time. Neurologic examination shows 3/5 strength of the lower extremities. Deep tendon reflexes are hyperreflexive. Babinski sign is present bilaterally. Sensory examination shows decreased sensation to pinprick below the T4 dermatome. He is unable to lie recumbent due to severe pain. An x-ray of the chest shows multiple round opacities of varying sizes in both lungs. Which of the following is the most appropriate next step in the management of this patient?", "answer": "Intravenous dexamethasone therapy", "options": {"A": "Radiation therapy", "B": "Intravenous dexamethasone therapy", "C": "Intravenous acyclovir therapy", "D": "Intravenous ceftriaxone and azithromycin therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["76 year old man", "brought", "physician", "wife", "low back pain", "weakness", "past 4 weeks", "pain", "sharp", "radiates", "left side", "burning quality", "cough occasionally productive of blood streaked sputum", "past", "months", "3.2 kg", "0", "weight loss", "time", "now unable to walk", "assistance", "constipation", "difficulty urinating", "past 2 weeks", "hypertension treated with enalapril", "smoked 1 pack", "cigarettes daily", "60 years", "temperature", "98", "pulse", "75 min", "blood pressure", "80 mm Hg", "oriented to person", "place", "time", "Neurologic examination shows 3/5 strength of", "lower extremities", "Deep tendon reflexes", "Babinski sign", "present", "Sensory examination shows decreased sensation", "pinprick", "T4 dermatome", "unable to", "recumbent due to severe pain", "x-ray of", "chest shows multiple round opacities", "sizes", "lungs", "following", "most appropriate next step", "management", "patient"]}
{"question": "A 32-year-old man arrives to his primary care physician to discuss his fear of flying. The patient reports that he has had a fear of flying since being a teenager. He went on a family vacation 15 years ago, and during the flight there was turbulence and a “rough landing”. Since then he has avoided flying. He did not go to his cousin’s wedding because it was out of the country. He also was unable to visit his grandmother for her 80th birthday. The last time his job asked him to meet a client out of state, he drove 18 hours instead of flying. Two years ago he promised his fiancé they could fly to Florida. Upon arrival at the airport, he began to feel dizzy, lightheaded, and refused to go through security. During the clinic visit, the patient appears anxious and distressed. He recognizes that his fear is irrational. He is upset that it is affecting his relationship with his wife. Additionally, his current job may soon require employees in his sales position to fly to meet potential clients. He is embarrassed to have a conversation with his manager about his fear of flying. Which of the following is the best therapy for the patient’s condition?", "answer": "Cognitive behavioral therapy", "options": {"A": "Alprazolam", "B": "Cognitive behavioral therapy", "C": "Fluoxetine", "D": "Psychodynamic psychotherapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "primary care physician to discuss", "fear of flying", "patient reports", "fear of flying", "teenager", "family vacation", "years", "flight", "landing", "then", "flying", "not go", "cousins wedding", "out", "country", "unable to visit", "grandmother", "80th", "last time", "job", "to meet", "client out", "state", "drove 18 hours", "flying", "Two years", "promised", "fly", "Florida", "arrival", "airport", "began to feel dizzy", "lightheaded", "refused to go", "security", "clinic visit", "patient appears anxious", "distressed", "fear", "irrational", "upset", "affecting", "relationship", "wife", "current job", "employees", "sales position to fly to meet potential clients", "embarrassed to", "conversation", "manager", "fear of flying", "following", "best therapy", "patients condition"]}
{"question": "A 75-year-old man presents to a medical clinic for evaluation of a large, tense, pruritic bulla on his inner thighs, abdomen, and lower abdomen. A skin biopsy is performed, which shows an epidermal basement membrane with immunoglobulin G (IgG) antibodies and linear immunofluorescence. Which of the following is the most likely cell junction to which the antibodies bind?", "answer": "Hemidesmosomes", "options": {"A": "Desmosomes", "B": "Gap junctions", "C": "Hemidesmosomes", "D": "Tight junctions"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "medical clinic", "evaluation", "large", "tense", "bulla", "inner thighs", "abdomen", "lower abdomen", "skin biopsy", "performed", "shows", "epidermal basement membrane", "immunoglobulin G", "antibodies", "linear immunofluorescence", "following", "most likely cell junction", "antibodies bind"]}
{"question": "A 16-year-old girl is brought to the physician by her father because of concerns about her behavior during the past 2 years. She does not have friends and spends most of the time reading by herself. Her father says that she comes up with excuses to avoid family dinners and other social events. She states that she likes reading and feels more comfortable on her own. On mental status examination, her thought process is organized and logical. Her affect is flat. Which of the following is the most likely diagnosis?", "answer": "Schizoid personality disorder", "options": {"A": "Schizoid personality disorder", "B": "Antisocial personality disorder", "C": "Schizophreniform disorder", "D": "Autism spectrum disorder"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "physician", "father", "concerns", "behavior", "past", "years", "not", "friends", "spends most of the time reading", "father", "to", "family dinners", "social events", "states", "likes reading", "feels more", "mental", "thought process", "organized", "logical", "affect", "flat", "following", "most likely diagnosis"]}
{"question": "Twelve hours after admission to the hospital because of a high-grade fever for 3 days, a 15-year-old boy has shortness of breath. During this period, he has had generalized malaise and a cough productive of moderate amounts of green sputum. For the past 10 days, he has had fever, a sore throat, and generalized aches; these symptoms initially improved, but worsened again over the past 5 days. His temperature is 38.7°C (101.7°F), pulse is 109/min, respirations are 27/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. There are decreased breath sounds and crackles heard over the upper right lung field. His hemoglobin concentration is 13.3 g/dL, leukocyte count is 15,000/mm3, and platelet count is 289,000/mm3. An x-ray of the chest shows a right upper-lobe infiltrate. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Streptococcus pneumoniae", "options": {"A": "Streptococcus pneumoniae", "B": "Mycoplasma pneumoniae", "C": "Chlamydophila pneumoniae", "D": "Haemophilus influenzae"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Twelve hours", "admission", "hospital", "high-grade fever", "3 days", "year old boy", "shortness of breath", "period", "generalized malaise", "cough productive", "moderate amounts", "green sputum", "past 10 days", "fever", "sore throat", "generalized aches", "symptoms initially improved", "worsened", "past 5 days", "temperature", "pulse", "min", "respirations", "27 min", "blood pressure", "100 70 mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "decreased breath sounds", "crackles heard", "upper right lung field", "hemoglobin concentration", "g/dL", "leukocyte count", "mm3", "platelet count", "mm3", "x-ray of", "chest shows", "right upper-lobe infiltrate", "following", "most likely cause", "patient's symptoms"]}
{"question": "An elderly man presents to his physician with complaints of difficulty breathing, easy fatigability, and bilateral leg swelling which began 2 months ago. His breathlessness worsens while walking, climbing the stairs, and lying flat on his back. He also finds it difficult to sleep well at night, as he often wakes up to catch his breath. His pulse is 98/min and blood pressure is 114/90 mm Hg. On examination, he has mild respiratory distress, distended neck veins, and bilateral pitting edema is evident on the lower third of his legs. His respiratory rate is 33/min, SpO2 is 93% in room air, and coarse crepitations are heard over the lung bases. On auscultation, the P2 component of his second heart sound is heard loudest at the second left intercostal space, and an S3 gallop rhythm is heard at the apex. Medication is prescribed for his symptoms which changes his cardiac physiology as depicted with the dashed line recorded post-medication. What is the mechanism of action of the prescribed medication?", "answer": "Decrease in transmembrane sodium gradient", "options": {"A": "Decrease in transmembrane sodium gradient", "B": "Preferential dilatation of capacitance vessels", "C": "Inhibition of aldosterone-mediated sodium reabsorption", "D": "Reduction in myocardial contractility"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["elderly man presents", "physician", "complaints", "difficulty breathing", "easy fatigability", "bilateral leg swelling", "began 2 months", "breathlessness worsens", "walking", "climbing", "stairs", "lying flat on", "back", "finds", "difficult to sleep well", "night", "often wakes up", "catch", "breath", "pulse", "98 min", "blood pressure", "90 mm Hg", "examination", "mild respiratory distress", "distended neck", "bilateral pitting edema", "evident", "lower third", "legs", "respiratory rate", "min", "room air", "coarse crepitations", "heard", "lung bases", "auscultation", "P2 component", "second heart", "heard loudest", "second left intercostal space", "S3", "heard", "apex", "Medication", "prescribed", "symptoms", "changes", "cardiac physiology", "dashed line recorded post medication", "mechanism of action", "prescribed medication"]}
{"question": "A 30-year-old man presents to his primary care physician with complaints of excessive fatigue and weakness for the last several weeks. He also complains of abdominal pain and constipation for the same duration. On further questioning, he reports that he has lost 8 pounds in the last 2 weeks. Past medical history and family history are insignificant. His temperature is 37.3° C (99.2° F), respirations are 21/min, pulse is 63/min, and blood pressure is 99/70 mm Hg. On physical examination, he is a tired-appearing, thin male. He has a bronze discoloration to his skin, but he denies being outside in the sun or any history of laying in tanning beds. What is the next best step in the management of this patient?", "answer": "Start him on both hydrocortisone and fludrocortisone therapy", "options": {"A": "Administer intravenous fludrocortisone", "B": "Start him on androgen replacement treatment", "C": "Start him on both hydrocortisone and fludrocortisone therapy", "D": "Order an ACTH stimulation test"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old man presents", "primary care physician", "complaints", "excessive fatigue", "weakness", "weeks", "abdominal pain", "constipation", "same duration", "further questioning", "reports", "lost", "pounds", "2 weeks", "Past medical history", "family history", "temperature", "99", "F", "respirations", "min", "pulse", "63 min", "blood pressure", "99 70 mm Hg", "physical examination", "tired appearing", "thin male", "bronze discoloration", "skin", "denies", "outside", "sun", "history", "laying", "tanning beds", "next best step", "management", "patient"]}
{"question": "A 27-year-old HIV positive female gave birth to a 7lb 2oz (3.2 kg) baby girl. The obstetrician is worried that the child may have been infected due to the mother's haphazard use of her anti-retroviral medications. Which of the following assays would a hospital use detect the genetic material of HIV if the child had been infected?", "answer": "Polymerase chain reaction", "options": {"A": "Enzyme-linked immunosorbent assay (ELISA)", "B": "Rapid HIV antibody test", "C": "Polymerase chain reaction", "D": "Southern blot"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old HIV positive female gave birth", "3.2 kg", "baby girl", "obstetrician", "worried", "child", "infected due to", "mother's", "use of", "retroviral medications", "following assays", "hospital use detect", "genetic material", "HIV", "child", "infected"]}
{"question": "A 53-year-old man presents to his physician’s office with a persistent cough which he has had over the last few months. He was diagnosed with chronic obstructive pulmonary disease (COPD) the previous year and since then has been on a short-acting β-agonist to help alleviate his symptoms. Since his diagnosis, he has quit smoking, a habit which he had developed about 30 years ago. He used to smoke about 2 packs of cigarettes daily. Today, he has come in with an increase in his symptoms. He tells his physician that he has been having a fever for the past 3 days, ranging between 37.8°–39°C (100°F–102.2°F). Along with this, he has a persistent cough with copious amounts of greenish-yellow sputum. He has also been having difficulty breathing. On examination, his temperature is 38.6°C (101.5°F), the respirations are 22/min, the blood pressure is 110/80 mm Hg, and the pulse is 115/min. Slight crackles and respiratory wheezes are prominent in the lower lung fields. His FEV1 is 57% of his normal predicted value. He is started on oxygen and a dose of oral prednisone. At this time, which of the following should also be considered as a treatment option?", "answer": "Doxycycline", "options": {"A": "Doxycycline", "B": "Ciprofloxacin", "C": "Erythromycin", "D": "Antibiotics would not be appropriate at this time"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "physicians office", "persistent cough", "last", "months", "diagnosed", "chronic obstructive pulmonary disease", "previous year", "since then", "short acting", "agonist to help", "symptoms", "diagnosis", "quit smoking", "habit", "30 years", "used to smoke", "packs", "cigarettes daily", "Today", "increase", "symptoms", "physician", "fever", "past 3 days", "ranging", "persistent cough", "copious amounts", "yellow", "difficulty breathing", "examination", "temperature", "respirations", "min", "blood pressure", "80 mm Hg", "pulse", "min", "Slight crackles", "respiratory wheezes", "prominent", "lower lung fields", "FEV1", "57", "normal predicted value", "started", "oxygen", "dose", "oral prednisone", "time", "following", "considered", "treatment option"]}
{"question": "An 8-year-old boy is brought to the physician because of headaches for the past 2 weeks. His headaches tend to occur in the morning and are associated with nausea and vomiting. One month ago, the patient was admitted to the hospital because of fever, irritability, and neck rigidity, and he was successfully treated with antibiotics. His temperature today is 37.5°C (98.5°F). An MRI of the brain shows bilateral ventricular enlargement and enlargement of the subarachnoid space. Which of the following is the most likely explanation of the patient's condition?", "answer": "Impaired CSF flow through the arachnoid granulations", "options": {"A": "Increased CSF production by the choroid plexus", "B": "Impaired CSF flow through the arachnoid granulations", "C": "Impaired CSF drainage into the subarachnoid space", "D": "Impaired CSF drainage into the fourth ventricle"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "of headaches", "past 2 weeks", "headaches", "to occur", "morning", "associated with nausea", "vomiting", "One month", "patient", "admitted", "hospital", "fever", "irritability", "neck rigidity", "treated with antibiotics", "temperature today", "98", "MRI of", "brain shows bilateral ventricular enlargement", "enlargement", "subarachnoid space", "following", "most likely explanation", "patient's"]}
{"question": "A previously healthy 2-year-old boy is brought to the physician because of a 10-day history of unsteady gait, frequent falls, and twitching of the extremities. Physical examination shows bilateral saccadic eye movement in all directions and brief, involuntary muscle contractions of the trunk and limbs. There is an ill-defined, nontender mass in the upper right abdomen. He undergoes surgical resection of the tumor. Histopathologic examination of this mass is most likely to show which of the following?", "answer": "Small blue cells arranged in rosettes around a central neuropil", "options": {"A": "Numerous immature lymphocytes in a starry sky pattern", "B": "Abortive glomeruli and tubules in a spindle cell stroma", "C": "Small blue cells arranged in rosettes around a central neuropil", "D": "Hepatocytes in fetal and embryonic stages of differentiation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "a 10 day history", "unsteady gait", "frequent falls", "twitching of the extremities", "Physical examination shows bilateral saccadic eye movement", "directions", "brief", "involuntary muscle contractions of", "trunk", "limbs", "ill defined", "nontender mass in", "upper right abdomen", "surgical resection", "tumor", "Histopathologic examination", "mass", "most likely to show", "following"]}
{"question": "In a study, 2 groups are placed on different statin medications, statin A and statin B. Baseline LDL levels are drawn for each group and are subsequently measured every 3 months for 1 year. Average baseline LDL levels for each group were identical. The group receiving statin A exhibited an 11 mg/dL greater reduction in LDL in comparison to the statin B group. Statistical analysis reports a p-value of 0.052. Which of the following best describes the meaning of this p-value?", "answer": "There is a 5.2% chance that A is more effective than B is due to chance", "options": {"A": "If 100 similar experiments were conducted, 5.2 of them would show similar results", "B": "There is a 5.2% chance that A is more effective than B is due to chance", "C": "There is a 94.8% chance that the difference observed reflects a real difference", "D": "This is a statistically significant result"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["study", "2 groups", "placed", "different statin medications", "statin", "statin", "Baseline", "levels", "drawn", "group", "measured", "3 months", "1 year", "Average baseline", "levels", "group", "identical", "group receiving statin A exhibited", "mg/dL greater reduction", "statin", "group", "Statistical analysis reports", "p-value", "0", "following best", "meaning", "value"]}
{"question": "A 32-year-old woman presents to the emergency department because she has a cord-like rash on her left calf that is red and painful to touch. She says that she has had multiple such lesions previously. Other medical history reveals that she has had 3 past spontaneous abortions at < 10 weeks of gestational age but has never been diagnosed with any diseases. She drinks socially but has never smoked or used drugs. She has never taken any medications except for over the counter analgesics and antipyretics. Physical exam shows that the cord-like lesion is tender, thick, and hardened on palpation. In addition, she has a lacy mottled violaceous rash on multiple extremities. Which of the following antibodies would most likely be found in this patient's blood?", "answer": "Anti-cardiolipin", "options": {"A": "Anti-cardiolipin", "B": "Anti-centromere", "C": "Anti-histone", "D": "Anti-ribonucleoprotein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "cord", "rash", "left calf", "red", "painful", "touch", "multiple", "lesions", "medical history reveals", "3 past spontaneous abortions", "10 weeks of gestational age", "never", "diagnosed", "diseases", "drinks", "never smoked", "used drugs", "never taken", "medications", "over the counter analgesics", "antipyretics", "Physical exam shows", "cord", "lesion", "tender", "thick", "hardened", "palpation", "addition", "lacy mottled violaceous rash", "multiple extremities", "following antibodies", "most likely", "found", "patient's blood"]}
{"question": "A 28-year-old female visits her physician for workup of a new onset diastolic murmur found on physical examination. Past medical history is insignificant. Her temperature is 37.0 degrees C, blood pressure is 115/75 mm Hg, pulse is 76/min, and respiratory rate is 16/min. The patient denies dyspnea, fatigue, and syncope. Transthoracic echocardiography reveals a large, pedunculated tumor in the left atrium. This patient is most at risk for:", "answer": "Acute arterial occlusion", "options": {"A": "Abrupt hypotension", "B": "Sudden cardiac death", "C": "Acute arterial occlusion", "D": "Septic embolism"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female visits", "physician", "workup", "new onset diastolic murmur found", "physical examination", "Past medical history", "temperature", "0 degrees C", "blood pressure", "75 mm Hg", "pulse", "76 min", "respiratory rate", "min", "patient denies dyspnea", "fatigue", "syncope", "Transthoracic echocardiography reveals", "large", "pedunculated tumor", "left atrium", "patient", "most", "risk"]}
{"question": "An 8-year-old girl presents to the emergency department with respiratory distress, facial edema, and a skin rash after eating a buffet dinner with her family. She was born at 39 weeks via spontaneous vaginal delivery, has met all developmental milestones and is fully vaccinated. Past medical history is significant for mild allergies to pet dander and ragweed, as well as a severe peanut allergy. She also has asthma. She normally carries both an emergency inhaler and EpiPen but forgot them today. Family history is noncontributory. The vital signs include: blood pressure 112/87 mm Hg, heart rate 111/min, respiratory rate 25/min, and temperature 37.2°C (99.0°F). On physical examination, the patient has severe edema over her face and an audible stridor in both lungs. Of the following options, which is the most appropriate next step in the management of this patient?", "answer": "IM epinephrine", "options": {"A": "IM epinephrine", "B": "oral diphenhydramine", "C": "extra-strength topical diphenhydramine", "D": "inhaled sodium cromolyn - mast cell stabilizer"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl presents", "emergency department", "respiratory distress", "facial edema", "skin rash", "eating", "dinner", "family", "born", "weeks", "spontaneous vaginal delivery", "met", "developmental milestones", "vaccinated", "Past medical history", "significant", "mild allergies", "pet dander", "ragweed", "severe peanut", "asthma", "carries", "emergency inhaler", "EpiPen", "forgot", "today", "Family history", "vital signs include", "blood pressure", "87 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "physical examination", "patient", "severe", "face", "stridor", "lungs", "following options", "most appropriate next step", "management", "patient"]}
{"question": "An investigator is studying the cell morphologies of the respiratory tract. He obtains a biopsy from the mainstem bronchus of a patient. On microscopic examination, the biopsy sample shows uniform squamous cells in layers. Which of the following best describes the histologic finding seen in this patient?", "answer": "Metaplasia", "options": {"A": "Metaplasia", "B": "Normal epithelium", "C": "Dysplasia", "D": "Anaplasia\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying", "cell morphologies", "respiratory tract", "obtains", "biopsy", "bronchus of", "patient", "microscopic examination", "biopsy sample shows uniform squamous cells", "layers", "following best", "histologic finding seen", "patient"]}
{"question": "A 32-year-old female complains to her gynecologist that she has had irregular periods for several years. She has severe facial acne and dense black hairs on her upper lip, beneath her hairline anterior to her ears, and the back of her neck. Ultrasound reveals bilateral enlarged ovaries with multiple cysts. Which of the following is the patient most likely increased risk of developing?", "answer": "Endometrial carcinoma", "options": {"A": "Endometrial carcinoma", "B": "Addison disease", "C": "Wegener granulomatosus", "D": "Eclampsia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "gynecologist", "irregular periods", "years", "severe facial acne", "dense black hairs", "upper lip", "hairline anterior", "ears", "the of", "neck", "Ultrasound reveals bilateral enlarged ovaries", "multiple cysts", "following", "patient", "likely increased risk"]}
{"question": "A 52-year-old fisherman presents to the clinic for an evaluation of a pigmented lesion on his neck. He states that he first noticed the lesion last year, but he believes that it has been slowly growing in size. Dermatopathology determines that the lesion contains neoplastic cells of melanocytic origin. Which of the following characteristics of the lesion would likely be found on physical examination?", "answer": "Brown-black color in one area of the lesion to red-white in a different area", "options": {"A": "Brown-black color in one area of the lesion to red-white in a different area", "B": "Macule that is 5mm in diameter", "C": "Well-circumscribed papule with smooth borders", "D": "Itching and pain to palpation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old fisherman presents", "clinic", "evaluation", "pigmented lesion", "neck", "states", "first", "lesion", "year", "slowly", "size", "lesion contains neoplastic cells", "melanocytic origin", "following characteristics", "lesion", "likely", "found", "physical examination"]}
{"question": "Two days after being admitted to the hospital following a fall, a 77-year-old woman complains of fatigue and headaches. During the fall she sustained a right-sided subdural hematoma. She has hypertension and hyperlipidemia. Her medications prior to admission were hydrochlorothiazide and atorvastatin. Vital signs are within normal limits. Physical and neurologic examinations show no abnormalities. Laboratory studies show:\nSerum\nNa+ 130 mEq/L\nK+ 4.0 mEq/L\nCl- 103 mEq/L\nHCO3- 24 mEq/L\nUrea nitrogen 14 mg/dL\nCreatinine 1.1 mg/dL\nOsmolality 270 mOsmol/kg H2O\nUrine\nSodium 45 mEq/L\nOsmolality 326 mOsmol/kg H2O\nA CT scan of the head shows an unchanged right-sided subdural hematoma. Which of the following is the most appropriate next step in management?\"", "answer": "Fluid restriction", "options": {"A": "Head elevation", "B": "Tolvaptan", "C": "Desmopressin", "D": "Fluid restriction"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Two days", "admitted", "hospital following", "fall", "year old woman", "fatigue", "headaches", "fall", "sustained", "right-sided subdural hematoma", "hypertension", "hyperlipidemia", "medications prior to admission", "hydrochlorothiazide", "atorvastatin", "Vital signs", "normal limits", "Physical", "neurologic examinations show", "abnormalities", "Laboratory studies show", "Serum", "mEq K", "4 0", "Cl", "HCO3", "24", "14 mg dL Creatinine 1", "mg dL Osmolality", "kg", "kg", "CT scan of", "head shows", "unchanged right-sided subdural hematoma", "following", "most appropriate next step", "management"]}
{"question": "An 18-month-old girl is brought to the pediatrician by her mother for vaginal bleeding. The mother states that she noticed the bleeding today, which appeared as brown discharge with clots in the patient’s diaper. The mother denies frequent nosebleeds or easy bruising. She also denies any known trauma. She does mention that the patient has been limping and complaining of left leg pain since a fall 2 months ago. On physical exam, there are multiple 2-3 cm hyperpigmented patches on the patient’s trunk. There is bilateral enlargement of the breasts but no pubic hair. The vaginal orifice is normal and clear with an intact hymen. A plain radiograph of the left lower leg shows patchy areas of lytic bone and sclerosis within the femoral metaphysis. Which of the following is associated with the patient’s most likely diagnosis?", "answer": "Polyostotic fibrous dysplasia", "options": {"A": "Bitemporal hemianopsia", "B": "Hypertension", "C": "Pheochromocytoma", "D": "Polyostotic fibrous dysplasia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old girl", "brought", "pediatrician", "mother", "vaginal bleeding", "mother states", "bleeding today", "appeared", "brown discharge", "clots", "patients diaper", "mother denies frequent nosebleeds", "easy bruising", "denies", "known trauma", "patient", "limping", "left leg pain", "fall", "months", "physical exam", "multiple", "hyperpigmented patches", "patients trunk", "bilateral enlargement", "breasts", "pubic hair", "vaginal orifice", "normal", "clear", "intact hymen", "plain radiograph of", "left lower leg shows patchy areas", "lytic bone", "sclerosis", "femoral metaphysis", "following", "associated with", "patients", "likely diagnosis"]}
{"question": "A 72-year-old woman is admitted to the hospital for treatment of unstable angina. Cardiac catheterization shows occlusion that has caused a 50% reduction in the diameter of the left circumflex artery. Resistance to blood flow in this vessel has increased by what factor relative to a vessel with no occlusion?", "answer": "16", "options": {"A": "64", "B": "16", "C": "8", "D": "4"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old woman", "admitted", "hospital", "treatment", "unstable angina", "Cardiac shows occlusion", "caused", "50", "reduction", "diameter", "left circumflex artery", "Resistance", "blood flow", "vessel", "increased", "factor relative to", "vessel", "occlusion"]}
{"question": "A 5-year-old boy is brought to the physician because of an irregular gait 3 days after receiving age-appropriate vaccinations. Examination of the lower extremities shows no redness or swelling. When the child stands on his right leg, his left leg drops and his pelvis tilts towards the left. Sensation to light touch is normal in both legs. This patient's symptoms are most likely due to the injection of the vaccine into which of the following locations?", "answer": "Superomedial quadrant of the right buttock", "options": {"A": "Inferolateral quadrant of the right buttock", "B": "Inferomedial quadrant of the right buttock", "C": "Inferomedial quadrant of the left buttock", "D": "Superomedial quadrant of the right buttock"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old boy", "brought", "physician", "of", "irregular gait 3 days", "receiving age appropriate vaccinations", "Examination", "the lower extremities shows", "redness", "swelling", "child stands", "right leg", "left leg drops", "pelvis tilts", "left", "Sensation", "light touch", "normal", "legs", "patient's symptoms", "most likely due to", "injection", "vaccine", "following locations"]}
{"question": "A 2-year-old boy is brought to the physician because of decreased appetite and abdominal pain for the last several weeks. Physical examination shows a well-appearing toddler with a palpable left-sided abdominal mass that does not cross the midline. A CT of the abdomen shows a large, necrotic tumor on the left kidney. Histological examination of the kidney mass shows primitive blastemal cells and immature tubules and glomeruli. This tissue is most likely derived from the same embryological structure as which of the following?", "answer": "Papillary muscles", "options": {"A": "Adrenal medulla", "B": "Thyroid gland", "C": "Papillary muscles", "D": "Anterior pituitary\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["2 year old boy", "brought", "physician", "decreased appetite", "abdominal pain", "weeks", "Physical examination shows", "well appearing toddler", "palpable left-sided abdominal mass", "not cross", "midline", "CT of", "abdomen shows", "large", "necrotic tumor", "the left kidney", "Histological", "of", "mass shows primitive blastemal cells", "immature", "glomeruli", "tissue", "most likely derived", "same embryological structure", "following"]}
{"question": "A 14-year-old boy is brought to the physician because of an increasing difficulty in hearing over the past several months. His mother says they have to speak at a higher volume for him to understand them. He also complains of having difficulty reading his favorite books because he is not able to see the words clearly. His father received a renal transplant in his 20s. The vital signs are within normal limits. The physical examination shows no abnormalities. Laboratory studies show:\nSerum\nUrea nitrogen 15 mg/dL\nCreatinine 1.0 mg/dL\nUrine\nBlood 1+\nProtein 1+\nRBC 15–17/hpf\nWBC 1–2/hpf\nThe audiometry shows bilateral high-frequency sensorineural hearing loss. The ophthalmologic examination shows anterior lenticonus. Which of the following best explains these findings?", "answer": "Alport syndrome", "options": {"A": "Alport syndrome", "B": "Fabry’s disease", "C": "Von Hippel-Lindau disease", "D": "Tuberous sclerosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "physician", "of", "increasing difficulty", "hearing", "past", "months", "mother", "speak", "higher volume", "to understand", "difficulty reading", "books", "not able to see", "words", "father received", "renal transplant", "20s", "vital signs", "normal limits", "physical examination shows", "abnormalities", "Laboratory studies show", "Serum Urea nitrogen", "mg/dL", "Urine", "Protein", "RBC", "12", "audiometry shows bilateral high-frequency sensorineural hearing loss", "ophthalmologic examination shows anterior lenticonus", "following best", "findings"]}
{"question": "A 16-year-old female presents to her primary care physician due to lack of menstruation. She has never had a period and is anxious that she is not “keeping up” with her friends. She states that her breasts began developing when she was 13, and she had a growth spurt around the same time. Review of systems reveals that she has also been getting headaches every few months over the last year with some photosensitivity and nausea each time. Ibuprofen relieves her symptoms. The patient is a competitive ice skater and has never been sexually active. Her mother has a history of migraine headaches, and her older sister has a history of bipolar disorder. Both underwent menarche at age 15. At this visit, the patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 118/65 mmHg, and respirations are 13/min. Her body mass index is 23.8 kg/m^2. Cardiopulmonary and abdominal exams are unremarkable. Both breasts are Tanner IV with no expressable discharge. Pelvic and axillary hair growth is also Tanner IV. The patient is unable to tolerate a full pelvic exam, but the part of the vaginal canal that is examined is unremarkable. Laboratory studies are ordered and are below:\n\nSerum:\nNa+: 139 mEq/L\nK+: 4.1 mEq/L\nCl-: 100 mEq/L\nHCO3-: 24 mEq/L\nUrea nitrogen: 12 mg/dL\nGlucose: 73 mg/dL\nCreatinine: 0.9 mg/dL\nCa2+: 9.7 mg/dL\nMg2+: 1.7 mEq/L\nAST: 11 U/L\nALT: 11 U/L\nFollicle Stimulating Hormone (FSH): 16.2 mIU/mL (4.7-21.5 mIU/ml)\nEstrogen: 240 pg/mL (64-357 pg/mL)\n\nAbdominal ultrasound is performed and shows a normal uterus and ovaries. Which of the following is the most likely diagnosis?", "answer": "Vaginal septum", "options": {"A": "Hyperprolactinemia", "B": "Imperforate hymen", "C": "Vaginal septum", "D": "Normal development"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female presents", "primary care physician due to lack of menstruation", "never", "period", "anxious", "not keeping", "friends", "states", "breasts began", "growth spurt", "same time", "Review of systems reveals", "getting headaches", "few months", "year", "photosensitivity", "nausea", "time", "Ibuprofen relieves", "symptoms", "patient", "competitive ice", "never", "sexually active", "mother", "history of migraine headaches", "older sister", "history of bipolar disorder", "menarche at age", "visit", "patients temperature", "98", "pulse", "70 min", "blood pressure", "65 mmHg", "respirations", "min", "body mass index", "23", "kg/m", "Cardiopulmonary", "abdominal exams", "unremarkable", "breasts", "Tanner IV", "discharge", "Pelvic", "axillary", "Tanner IV", "patient", "unable to", "full pelvic exam", "part of", "vaginal canal", "examined", "unremarkable", "Laboratory studies", "ordered", "Serum", "Na", "mEq/L K", "4.1 mEq/L Cl", "100 mEq/L HCO3", "mEq/L Urea nitrogen", "mg/dL Glucose", "mg/dL Creatinine", "0.9 mg/dL Ca2", "9", "mg dL Mg2", "1.7 mEq/L AST", "U/L ALT", "U/L Follicle Stimulating Hormone", "mIU mL", "ml", "Estrogen", "pg/mL", "64", "pg/mL", "Abdominal ultrasound", "performed", "shows", "normal uterus", "ovaries", "following", "most likely diagnosis"]}
{"question": "A 35-year-old man presents to the emergency room due to shortness of breath that started an hour ago while playing football with some friends. He has had similar episodes in the past when he also had to be rushed to the hospital. Physical examination shows body temperature is 37.2°C (98.9°F), pulse rate is 100/min, respiratory rate is 28/min and blood pressure is 110/60 mm Hg. Also, it shows decreased breath sounds on both sides, the peak expiratory flow rate is 200 L/min and SpO2 is 89% on room air. The man is given an initial treatment with nebulization using an inhaled short-acting β-agonist. An arterial blood gas analysis shows the following:\npH 7.48\nPaO2 59 mm Hg\nPaCO2 26 mm Hg\nHCO3- 26 mEq/L\nAfter administering oxygen by mask, the man’s PaO2 increases to 75 mm Hg. Which of the following is the most likely cause of this patient’s condition?", "answer": "Asthma attack", "options": {"A": "Asthma attack", "B": "Carbon monoxide (CO) poisoning", "C": "Neuromuscular disease", "D": "Acute respiratory distress syndrome (ARDS)"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old man presents", "emergency room due to shortness of breath", "started", "hour", "playing football", "friends", "similar episodes", "past", "to", "rushed", "hospital", "Physical examination shows body temperature", "98 9F", "pulse rate", "100 min", "respiratory rate", "min", "blood pressure", "60 mm Hg", "shows decreased breath sounds", "sides", "peak expiratory flow rate", "200", "min", "room air", "man", "given", "initial treatment", "nebulization using", "inhaled short acting", "agonist", "arterial blood gas analysis shows", "following", "pH 7 48 PaO2 59 mm Hg", "HCO3", "mEq/L", "administering oxygen", "mask", "mans PaO2 increases", "75 mm Hg", "following", "most likely cause", "patients condition"]}
{"question": "A 48-year-old homeless male is brought to the emergency department, by the police, for altered mental status. Past medical records are unavailable. A physical exam on admission reveals scleral icterus and a flapping tremor of the wrists during extension. The patient is admitted to the hospital and his treatment is started after appropriate investigation. The next morning on rounds, he complains of eleven episodes of diarrhea and near-constant flatulence overnight. His mental status has improved and his hand tremor has resolved. Which of the following medications did this patient most likely receive after admission?", "answer": "Lactulose", "options": {"A": "Thiamine", "B": "Lactulose", "C": "Naloxone", "D": "Rifaximin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old homeless male", "brought", "emergency department", "police", "altered mental status", "Past medical records", "unavailable", "physical exam on admission reveals scleral icterus", "flapping tremor", "wrists", "extension", "patient", "admitted", "hospital", "treatment", "started", "appropriate investigation", "next morning", "rounds", "of eleven episodes", "diarrhea", "near constant flatulence overnight", "mental status", "improved", "hand tremor", "resolved", "following medications", "patient", "likely receive", "admission"]}
{"question": "A 61-year-old man presents to his primary care provider complaining of abdominal pain and constipation. He reports a 4-day history of steady right lower quadrant pain. He has had one small bowel movement in 4 days. Normally he has a bowel movement once a day. His medical history is notable for poorly controlled hypertension and hyperlipidemia. He takes enalapril, hydrochlorothiazide, aspirin, and atorvastatin. He has a 40 pack-year smoking history and drinks 3-4 beers per day. His diet consists primarily of fast food. His temperature is 101.8°F (38.8°C), blood pressure is 160/95 mmHg, pulse is 90/min, and respirations are 16/min. A review of the patient’s medical record reveals colonoscopy results from 1 year ago. Relevant findings included multiple small, pedunculated polyps which were removed, multiple colonic mucosal outpouchings, and no other masses. This patient’s condition is most strongly associated with which of the following disorders?", "answer": "Ehlers-Danlos syndrome", "options": {"A": "Alpha-1-antitrypsin deficiency", "B": "Autosomal recessive polycystic kidney disorder", "C": "Ehlers-Danlos syndrome", "D": "Goodpasture syndrome"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["61 year old man presents", "primary care provider", "abdominal pain", "constipation", "reports", "4-day history", "steady right lower quadrant pain", "one small bowel movement", "days", "bowel movement", "day", "medical history", "notable", "poorly controlled hypertension", "hyperlipidemia", "takes enalapril", "hydrochlorothiazide", "aspirin", "atorvastatin", "40 pack-year smoking history", "drinks 3 beers", "day", "diet consists", "fast food", "temperature", "blood pressure", "95 mmHg", "pulse", "90 min", "respirations", "min", "review", "patients medical record reveals colonoscopy results", "year", "Relevant findings included multiple small", "pedunculated polyps", "removed", "multiple colonic mucosal", "masses", "patients condition", "most", "associated", "following disorders"]}
{"question": "A 67-year-old man is brought to the emergency department with sudden onset of slurred speech. The patient’s eldest daughter says that he couldn’t move his arm during the episode. Past medical history is significant for hypertension and a hemorrhagic stroke 6 years ago, which was treated surgically. After admission, the patient gets increasingly worse and loses consciousness. A noncontrast CT of the head shows a subarachnoid hemorrhage (SAH). The patient is taken to the operating room, where the SAH evacuated, and the vessel is repaired. Postoperatively, the patient is unresponsive. Several days later, a repeat CT of the head shows an enlarging aneurysm in a different vessel in the brain. The patient’s daughter is asked to consent to a non-emergent, life-saving operation since the patient is in a comatose state. She does not consent to the operation even though the physician stresses it would be life-saving. Upon further discussion, the physician finds out that the patient was abusive and neglectful to his children, and the daughter wants “to live in peace.” The patient has no written advanced directive. Which of the following is the most appropriate course of action?", "answer": "Contact another family member for consent", "options": {"A": "Follow the daughter’s wishes to withhold the operation", "B": "Refer this case to the court", "C": "Contact another family member for consent", "D": "Report the daughter to the police"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "brought", "emergency department", "sudden onset", "slurred speech", "patients", "daughter", "move", "arm", "episode", "Past medical history", "significant", "hypertension", "hemorrhagic stroke", "years", "treated surgically", "admission", "patient gets", "worse", "consciousness", "CT of", "head shows", "subarachnoid hemorrhage", "patient", "taken", "operating room", "SAH", "vessel", "repaired", "patient", "unresponsive", "days later", "repeat CT of", "head shows", "enlarging aneurysm", "different vessel", "brain", "patients daughter", "to consent", "non-emergent", "life saving operation", "patient", "comatose state", "not consent", "operation", "physician stresses", "life saving", "further discussion", "physician finds out", "patient", "neglectful", "children", "daughter", "to live", "peace", "patient", "written advanced directive", "following", "most appropriate course", "action"]}
{"question": "A 50-year-old man with congestive heart failure (CHF) was started on an experimental analog of atrial natriuretic peptide. Which of the following would he expect to experience?", "answer": "Increased glomerular filtration rate, restricted aldosterone release, vascular smooth muscle dilation", "options": {"A": "Increased water reabsorption by the renal collecting ducts", "B": "Vasoconstriction, increased blood pressure, aldosterone release", "C": "Increased glomerular filtration rate, restricted aldosterone release, vascular smooth muscle dilation", "D": "Increased plasma calcium and decreased renal reabsorption of phosphate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["50 year old man", "congestive heart failure", "started", "experimental analog", "atrial natriuretic peptide", "following", "to experience"]}
{"question": "A 56-year-old man is brought to the emergency room after a motor vehicle accident. The patient’s vitals are as follows: blood pressure 80/40 mm Hg, heart rate 111/min, respiratory rate 39/min, and temperature 37.1°C (98.8℉). On physical examination, the patient is unconscious with a GCS of 9/15 and is cyanotic. There are open fractures of the left femur and left tibia, a likely shoulder dislocation, multiple contusions on the limbs and thorax, and a puncture wound on the left side of his chest. There are no breath sounds on the left side and there is hyperresonance to percussion on the left. Preparations are made for an emergency needle thoracostomy to be performed to treat this patient’s likely tension pneumothorax. Which one of the following is the best choice to provide informed consent for this procedure?", "answer": "Informed consent is not needed in this case", "options": {"A": "The patient’s closest relatives (spouse, child or parent), who must be brought to the hospital as fast as possible", "B": "One of the witnesses at the scene of the car accident, who should be brought to the hospital as fast as possible", "C": "The hospital ethics committee", "D": "Informed consent is not needed in this case"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency room", "motor vehicle accident", "patients", "follows", "blood pressure 80 40 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "physical examination", "patient", "unconscious", "GCS", "cyanotic", "open fractures of", "left femur", "left tibia", "likely shoulder dislocation", "multiple contusions", "limbs", "thorax", "puncture wound", "left side", "chest", "breath sounds", "left side", "hyperresonance", "percussion", "left", "Preparations", "made", "emergency needle thoracostomy to", "performed to treat", "patients likely tension pneumothorax", "one", "following", "best choice to provide informed consent for", "procedure"]}
{"question": "A group of researchers wants to evaluate how often the human immunodeficiency virus (HIV) is related to high-risk behaviors in female sex workers from their country. An additional aim is to evaluate the association between HIV acquisition and certain sociodemographic factors. The researchers collect data through interviewer-administered questionnaires (for behavioral and sociodemographic data) as well as through clinical and serological evaluation/screening methods for HIV and other sexually transmitted infections. Which of the following could be the main outcome measure of their study?", "answer": "Prevalence", "options": {"A": "Incidence", "B": "Prevalence", "C": "Hazard rate", "D": "Attributable risk"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["A group", "researchers", "to evaluate how often", "human immunodeficiency virus", "related", "high-risk behaviors", "female sex workers", "country", "additional aim", "to evaluate", "association", "HIV acquisition", "certain", "factors", "researchers", "data", "interviewer administered questionnaires", "behavioral", "data", "as well", "clinical", "serological evaluation screening methods", "HIV", "sexually transmitted infections", "following", "main outcome", "study"]}
{"question": "A 53-year-old man comes to the physician because of a 2-month history of multiple episodes of small amounts of blood in his stools. Examination shows pale conjunctivae. His hemoglobin concentration is 8.3 g/dL and mean corpuscular volume is 72μm3. Colonoscopy shows a 2.3-cm polypoid mass in the ascending colon. A photomicrograph of a biopsy specimen of the lesion is shown. Which of the following processes is most likely to be involved in the pathogenesis of this patient's condition?", "answer": "Impaired degradation of β-catenin", "options": {"A": "Underexpression of COX-2", "B": "Increased phosphorylation of serine and threonine", "C": "Impaired degradation of β-catenin", "D": "Abnormal transfer of phosphate to cellular proteins"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "of", "2 month history", "multiple episodes", "small amounts", "blood", "stools", "Examination shows pale conjunctivae", "hemoglobin concentration", "g/dL", "mean corpuscular volume", "Colonoscopy shows", "2.3-cm polypoid mass", "ascending", "photomicrograph", "biopsy", "lesion", "shown", "following processes", "most likely to", "involved", "pathogenesis", "patient's condition"]}
{"question": "A 68-year-old female presents to her primary care physician with a 7-month history of fatigue and low back pain. Her pain is not improved by over the counter analgesics. Laboratory analysis is notable for a calcium level of 11.5 mg/dL, creatinine level of 2.0 mg/dL, and blood urea nitrogen level of 30 mg/dL. Large eosinophilic casts are seen on renal biopsy. Which of the following findings is most likely to be seen on peripheral blood smear?", "answer": "Linear aggregations of red blood cells", "options": {"A": "Abundant reticulocytes", "B": "Linear aggregations of red blood cells", "C": "Schistocytes", "D": "Leukocytosis with abundant mature myeloid cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["68 year old female presents", "primary care physician", "month history", "fatigue", "low back pain", "pain", "not improved", "over the counter analgesics", "Laboratory analysis", "notable", "calcium level", "5 mg/dL", "creatinine level", "2.0 mg/dL", "blood urea nitrogen level", "30 mg/dL", "Large eosinophilic casts", "seen", "renal biopsy", "following findings", "most likely to", "seen", "peripheral blood smear"]}
{"question": "A 95-year-old woman who is a resident at a long term care facility, got up from her chair, tripped on a rug, and fell on her right knee. She could not get up without assistance and complained of severe pain in her right hip and buttock. The nurse who evaluated her tried to stand her up, but when the patient tried to stand on her right leg, she dropped her left hip and lost her balance. The nurse then recognized that her patient had a foreshortened right leg fixed in the adducted position and a large swelling in her right buttock. At the receiving hospital, the patient was confused and, though she knew her name, she couldn’t remember the date and insists to leave the hospital immediately to see her family. Past medical history includes diabetes, congestive heart failure, and incontinence. She is currently taking metformin, lisinopril, hydrochlorothiazide, metoprolol, and oxybutynin. Physical exam confirmed the nurse’s findings. Radiographs proved the presence of a right posterior hip dislocation without fractures. What medication is most likely associated with this patient’s confusion?", "answer": "Oxybutynin", "options": {"A": "Metformin", "B": "Oxybutynin", "C": "Metoprolol", "D": "Lisinopril"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["95 year old woman", "resident", "long term care facility", "chair", "tripped", "rug", "fell", "right knee", "not get", "assistance", "severe pain", "right hip", "buttock", "nurse", "evaluated", "to stand", "patient", "to stand", "right leg", "dropped", "left hip", "lost", "balance", "nurse then", "patient", "right leg fixed", "adducted position", "large swelling", "right", "receiving hospital", "patient", "confused", "name", "remember", "date", "to leave", "hospital immediately to see", "family", "Past includes diabetes", "congestive heart failure", "incontinence", "currently taking metformin", "lisinopril", "hydrochlorothiazide", "metoprolol", "oxybutynin", "Physical exam confirmed", "nurses findings", "Radiographs", "presence of", "right posterior hip dislocation", "fractures", "medication", "most likely associated with", "patients confusion"]}
{"question": "A 26-year-old woman comes to the clinic for an annual wellness examination. She is healthy with no prior history of significant illness. She exercises 3-4 times a week and eats a plant-based diet with no carbonated drinks. When asked if anything is bothering her, she reports that she has been having recurring episodes of sneezing, congestion, and itchy eyes for the past year. She denies any fever, sick contacts, cough, headaches, chest pain, urinary symptoms, or constipation/diarrhea during these episodes. She is told to take a medication to alleviate her symptoms as needed. What is the likely mechanism of action of the medication in question?", "answer": "Alpha-adrenergic agonist", "options": {"A": "Alpha-adrenergic agonist", "B": "Competitive blockage of muscarinic receptors", "C": "Disruption of disulfide bonds", "D": "Short acting beta-2 agonist"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "clinic", "annual wellness examination", "healthy", "prior history", "significant illness", "exercises 3", "times", "week", "eats", "plant based diet", "carbonated drinks", "reports", "recurring episodes of sneezing", "congestion", "itchy eyes", "past year", "denies", "fever", "sick contacts", "cough", "headaches", "chest pain", "urinary symptoms", "constipation/diarrhea", "episodes", "to take", "medication to", "symptoms as needed", "likely mechanism of action", "medication", "question"]}
{"question": "A 27-year-old woman was referred to a dermatology clinic due to a changing discoloration of her fingers from white to red to blue. Although she has not had any recent changes in her daily routines, she also complains of increasing fatigue, muscle weakness, and weight loss. She has a blood pressure of 126/77 mm Hg, respiratory rate of 14/min, and heart rate of 88/min. Physical examination reveals regular heart and lung sounds. Anti-U1 RNP antibodies and increased creatinine kinase were found in her serum. What is the most likely diagnosis in this patient?", "answer": "Mixed connective tissue disease", "options": {"A": "Mixed connective tissue disease", "B": "Polymyositis", "C": "Systemic sclerosis", "D": "Rheumatoid arthritis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old woman", "referred", "dermatology clinic due to", "changing discoloration", "fingers", "white", "red", "blue", "not", "recent changes", "daily routines", "increasing fatigue", "muscle weakness", "weight loss", "blood pressure", "mm Hg", "respiratory rate", "min", "heart rate of 88 min", "Physical examination reveals regular heart", "lung sounds", "Anti-U1 RNP antibodies", "increased creatinine kinase", "found", "serum", "most likely diagnosis", "patient"]}
{"question": "A 32-year-old woman presents to the physician because she feels depressed, has difficulty sleeping, has a poor appetite, and has had a problem concentrating for the past 3 months. During this time, she has also has had low energy and has lost interest in playing the guitar. During high school, the patient went through similar episodes of low mood and poor sleep. At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy. There is no evidence of suicidal ideation. Her physician offers to prescribe a medication for her current symptoms. Treatment with which of the following drugs should be avoided in this patient?", "answer": "Bupropion", "options": {"A": "Bupropion", "B": "Citalopram", "C": "Fluoxetine", "D": "Trazodone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "physician", "feels depressed", "difficulty sleeping", "poor appetite", "problem concentrating", "past 3 months", "time", "low energy", "lost interest", "playing", "high school", "patient", "similar episodes of low mood", "poor sleep", "time", "repeatedly", "binge eating", "purging behavior", "referred", "therapy", "evidence", "suicidal ideation", "physician", "to", "medication", "current symptoms", "Treatment", "following drugs", "patient"]}
{"question": "A 52-year-old man comes to the physician for an annual physical examination. He reports that his vision has progressively improved over the past 6 months and he no longer needs the glasses he used while driving. He has hypertension and type 2 diabetes mellitus. Current medications include glyburide, hydrochlorothiazide, and enalapril. Examination shows 20/20 vision bilaterally. Fundoscopy shows a few microaneurysms of retinal vessels. Which of the following is the most likely explanation for this patient's improved vision?", "answer": "Denaturation of lens protein", "options": {"A": "Denaturation of lens protein", "B": "Liquefication of the vitreous body", "C": "Increased ciliary muscle tone", "D": "Increased lens elasticity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "annual physical examination", "reports", "vision", "improved", "past 6 months", "longer needs", "glasses", "used", "driving", "hypertension", "type 2 diabetes mellitus", "Current medications include glyburide", "hydrochlorothiazide", "enalapril", "Examination shows 20/20 vision", "Fundoscopy shows", "few microaneurysms", "retinal", "following", "most likely explanation", "patient's improved vision"]}
{"question": "A 21-year-old woman presents to the emergency room with right arm pain and limited range of motion. She does not recall trauma to the arm. She also complains of diarrhea and nausea. She is sexually active with one male partner and admits to having pain during intercourse. There is vague and diffuse tenderness to palpation in all four abdominal quadrants. No erythema or edema is noted on the right arm. The fecal occult test is negative. Past records show that this patient has been in the ER 7 times in the past year with similar symptoms. Which of the following is the most likely diagnosis?", "answer": "Somatization disorder", "options": {"A": "Ulcerative colitis", "B": "Illness anxiety disorder", "C": "Somatization disorder", "D": "Somatoform pain disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["21-year-old woman presents", "emergency room", "right arm pain", "limited range of motion", "not recall trauma", "arm", "diarrhea", "nausea", "sexually active", "one male partner", "admits", "pain", "intercourse", "vague", "diffuse tenderness", "palpation", "four abdominal", "erythema", "edema", "noted", "right arm", "fecal occult test", "negative", "Past records show", "patient", "ER", "times", "past year", "similar symptoms", "following", "most likely diagnosis"]}
{"question": "A 22-year-old man presents to a psychiatrist complaining of mood fluctuations. He is accompanied by his mother who reports that the patient recently experienced a 5-day episode of minimal sleep and unusual levels of energy. The patient admits to spending $2,000 of his parent’s money, without asking, on a down payment for a motorcycle. The episode resolved after 5 days, at which point the patient felt guilty and upset. The patient’s medical history is notable for multiple month-long episodes in the past 2 years of feeling sad, sleeping more than usual, being uninterested in his hobbies, and feeling constantly tired and guilty. The patient has a history of severe meningoencephalitis at the age of 17 requiring four days in the intensive care unit. During that episode, he reported seeing monkeys in his hospital room. On exam, he is a well-appearing, cooperative male in no acute distress. He is alert and oriented with a normal affect. He states that he feels sad and guilty about what happens. He denies suicidal ideation. Which of the following is the most likely diagnosis in this patient?", "answer": "Bipolar II disorder", "options": {"A": "Bipolar II disorder", "B": "Cyclothymic disorder", "C": "Persistent depressive disorder", "D": "Schizoaffective disorder"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "psychiatrist", "mood fluctuations", "mother", "reports", "patient recently experienced", "5-day episode of minimal sleep", "unusual levels", "energy", "patient admits", "spending", "parents money", "down payment", "motorcycle", "episode resolved", "5 days", "point", "patient felt guilty", "upset", "patients medical history", "notable", "multiple month long episodes", "past", "years", "feeling sad", "sleeping more", "usual", "hobbies", "feeling constantly tired", "guilty", "patient", "history", "severe meningoencephalitis", "age", "four days", "intensive care unit", "episode", "reported seeing monkeys", "hospital room", "exam", "well appearing", "cooperative male", "acute distress", "alert", "oriented", "normal affect", "states", "feels sad", "guilty", "happens", "denies suicidal ideation", "following", "most likely diagnosis", "patient"]}
{"question": "A 32-year-old woman comes to the emergency department because a 5-week history of abdominal pain and bloody diarrhea that has worsened in the past 24 hours. She was diagnosed with ulcerative colitis 1 year ago but has had difficulty complying with her drug regimen. Her temperature is 38.2°C (100.8°F), pulse is 120/min, and blood pressure is 92/56 mm Hg. Examination shows a distended, rigid abdomen and hypoactive bowel sounds. Fluid resuscitation is initiated. In addition to complete bowel rest, which of the following is the most appropriate next step in management of this patient?", "answer": "Abdominal x-ray", "options": {"A": "Abdominal CT scan with contrast", "B": "CT angiography", "C": "Abdominal x-ray", "D": "Colonoscopy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "emergency department", "5 week history", "abdominal pain", "bloody diarrhea", "worsened", "past 24 hours", "diagnosed", "ulcerative colitis", "year", "difficulty complying", "drug regimen", "temperature", "100", "pulse", "min", "blood pressure", "mm Hg", "Examination shows", "distended", "rigid abdomen", "hypoactive bowel sounds", "Fluid resuscitation", "initiated", "complete bowel rest", "following", "most appropriate next step", "management", "patient"]}
{"question": "A 55-year-old man recovering from knee replacement surgery complains of breathlessness in the postoperative ward. He has been confined to bed for the past 5 days and is under observation. He felt a sudden difficulty in breathing and called for the ward nurse. He says that he is unable to take deep breaths and has a sharp pain on the right side of his chest with each inspiration. His temperature is 37.5°C (99.8°F), the pulse is 111/min, the respirations are 31/min, and the blood pressure is 85/55 mm Hg. He experiences pain in his right calf on dorsiflexion. There are no other prominent findings on physical examination. His chest X-ray does not show anything significant. The ECG reveals sinus tachycardia. Which of the following is the best course of management at this time?", "answer": "Subcutaneous fondaparinux", "options": {"A": "Subcutaneous fondaparinux", "B": "Inferior vena cava filter", "C": "Ventilation-perfusion scan", "D": "Lower extremity doppler"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man recovering from knee surgery", "breathlessness", "postoperative ward", "confined to bed", "past", "days", "observation", "felt", "sudden difficulty", "breathing", "called", "ward nurse", "unable to take deep breaths", "pain", "right side", "chest", "inspiration", "temperature", "99", "pulse", "min", "respirations", "31 min", "blood pressure", "85 55 mm Hg", "experiences pain in", "right calf", "prominent findings", "physical examination", "chest X-ray", "not show", "significant", "ECG reveals sinus tachycardia", "following", "best course", "management", "time"]}
{"question": "A 62-year-old man is brought to his primary care physician by his wife who is concerned about the patient's frequent falls. Approximately 6 months ago, she started noticing that he was walking more slowly than usual. He has fallen more than 6 times in the past month, and she is worried that he will sustain a serious injury if he does not stop falling. The patient is a retired banking executive and was active as a triathlete until the age of 60. He does not smoke and drinks 2-3 alcoholic beverages per day. His family history is notable for normal pressure hydrocephalus in his mother and Alzheimer dementia in his father. His temperature is 97.8°F (36.6°C), blood pressure is 131/81 mmHg, pulse is 68/min, and respirations are 19/min. On exam, his movements appear slowed and forced. He shuffles his feet when he walks. Tone is increased in his upper and lower extremities bilaterally. This patient's condition is most strongly associated with which of the following histologic findings on brain autopsy?", "answer": "Intracellular inclusions of alpha-synuclein", "options": {"A": "Accumulations of beta-pleated sheets", "B": "Atrophy of the caudate nucleus", "C": "Intracellular inclusions of alpha-synuclein", "D": "Intracellular inclusions of hyperphosphorylated tau"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old man", "brought", "primary care physician", "wife", "concerned", "patient's frequent falls", "Approximately", "months", "started", "walking more slowly", "usual", "fallen", "times", "past month", "worried", "sustain", "serious injury", "not stop falling", "patient", "retired banking executive", "active", "age", "60", "not smoke", "drinks 2 alcoholic beverages", "day", "family history", "notable", "normal pressure hydrocephalus", "mother", "Alzheimer dementia", "father", "temperature", "97", "36", "blood pressure", "81 mmHg", "pulse", "68 min", "respirations", "min", "exam", "movements appear slowed", "forced", "shuffles", "feet", "walks", "Tone", "increased", "upper", "lower extremities", "patient's condition", "most", "associated with", "following histologic findings", "brain autopsy"]}
{"question": "A 16-month-old boy is brought to the physician by his mother for a regular check-up. His mother says that he has not yet begun to walk. He is exclusively breastfed. He is at the 20th percentile for length, 10th percentile for weight, and 50th percentile for head circumference. Physical examination shows erosion of the enamel on the lingual surface of the incisors and carious molars. He has frontal bossing. His wrists are widened, his legs appear bowed, and there is beading of the ribs. Which of the following is the most likely underlying cause of this patient's condition?", "answer": "Impaired growth plate mineralization", "options": {"A": "Deficiency of cofactor for prolyl and lysyl hydroxylase", "B": "Defect in type I collagen", "C": "Impaired growth plate mineralization", "D": "Mutation of fibroblast growth factor receptor 3"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "physician", "mother", "regular check-up", "mother", "not", "begun to walk", "breastfed", "percentile", "length", "percentile", "weight", "50th percentile", "head circumference", "Physical examination shows erosion of", "enamel", "lingual surface of", "incisors", "molars", "frontal bossing", "wrists", "widened", "legs appear bowed", "beading of", "ribs", "following", "most likely underlying cause", "patient's condition"]}
{"question": "A 55-year-old man is brought to the emergency department with altered mental status. The patient is in acute distress and cannot provide history due to disorientation. Temperature is 38.7°C (101.6°F), blood pressure is 80/50 mm Hg, pulse is 103/min, respiratory rate is 22/min, and BMI is 20 kg/m2. On examination, his sclera and skin are icteric. On abdominal examination, the patient moans with deep palpation to his right upper quadrant.\nLaboratory test\nComplete blood count\nHemoglobin 14.5 g/dL\nMCV 88 fl\nLeukocytes 16,500/mm3\nPlatelets 170,000/mm3\nBasic metabolic panel\nSerum Na+ 147 mEq/L\nSerum K+ 3.8 mEq/L\nSerum Cl- 106 mEq/L\nSerum HCO3- 25 mEq/L\nBUN 30 mg/dL\nSerum creatinine 1.2 mg/dL\nLiver function test\nTotal bilirubin 2.8 mg/dL\nAST 50 U/L\nALT 65 U/L\nALP 180 U/L\nThe patient is treated urgently with intravenous fluid, dopamine, and broad spectrum antibiotics. The patient’s blood pressure improves to 101/70 mm Hg. On ultrasound of the abdomen, the common bile duct is dilated. What is the best next step in the management of this patient?", "answer": "ERCP", "options": {"A": "ERCP", "B": "MRCP", "C": "Percutaneous transhepatic cholangiogram", "D": "CT abdomen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man", "brought", "emergency department", "altered mental status", "patient", "acute distress", "provide history due to disorientation", "Temperature", "blood pressure", "80 50 mm Hg", "pulse", "min", "respiratory rate", "min", "BMI", "20 kg/m2", "examination", "sclera", "skin", "icteric", "abdominal examination", "patient moans", "deep palpation", "blood", "Serum", "Cl", "mg", "2 mg", "bilirubin", "patient", "treated", "intravenous fluid", "dopamine", "broad spectrum antibiotics", "patients blood pressure improves", "70 mm Hg", "ultrasound of", "abdomen", "common bile duct", "dilated", "best next step", "management", "patient"]}
{"question": "A 31-year-old woman comes to the physician because of a 5-month history of intermittent flank pain. Over the past 2 years, she has had five urinary tract infections. Her blood pressure is 150/88 mm Hg. Physical examination shows bilateral, nontender upper abdominal masses. Serum studies show a urea nitrogen concentration of 29 mg/dL and a creatinine concentration of 1.4 mg/dL. Renal ultrasonography shows bilaterally enlarged kidneys with multiple parenchymal anechoic masses. Which of the following is the most likely diagnosis?", "answer": "Autosomal dominant polycystic kidney disease", "options": {"A": "Medullary sponge kidney", "B": "Autosomal dominant polycystic kidney disease", "C": "Autosomal recessive polycystic kidney disease", "D": "Obstructive cystic dysplasia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["31 year old woman", "physician", "5 month history", "intermittent flank", "past", "years", "five urinary tract infections", "blood pressure", "88 mm Hg", "Physical examination shows bilateral", "nontender upper abdominal masses", "Serum studies show", "urea", "29 mg/dL", "creatinine concentration", "mg/dL", "Renal ultrasonography shows", "enlarged kidneys", "multiple parenchymal", "masses", "following", "most likely diagnosis"]}
{"question": "A 39-year-old African-American woman presents to the emergency room with hip pain. She has a past medical history significant for sarcoidosis which was recently diagnosed 6 months ago and is currently being treated. She reports that the pain started 2 weeks ago and is localized to the left hip and groin. The pain has been getting progressively more intense. Her temperature is 98.1°F (36.7°C), blood pressure is 122/78 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for pain with manipulation without restriction of range of motion of the hip. Which of the following is the most sensitive test for this condition?", "answer": "MRI of the hip", "options": {"A": "MRI of the hip", "B": "Radiograph of the hip", "C": "Radionuclide scan of the hip", "D": "Ultrasound of the hip"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old African-American woman presents", "emergency room", "hip pain", "past medical history significant", "sarcoidosis", "recently diagnosed", "months", "currently", "treated", "reports", "pain started 2 weeks", "localized", "left hip", "groin", "pain", "getting", "intense", "temperature", "98", "36", "blood pressure", "mm Hg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "pain", "manipulation", "restriction of range", "motion", "hip", "following", "most sensitive test", "condition"]}
{"question": "A 22-year-old man from Nepal presents to the emergency department complaining of swelling and pain in his right testicle. The patient states that he just arrived in the United States to live with his wife, with whom he is monogamous. The patient denies painful urination or urethral discharge, but admits that 10 days ago he “felt like he had a fever” and the right side of his face was swollen and painful. Which of the following is characteristic of the most likely diagnosis?", "answer": "Preventable by a live attenuated vaccine", "options": {"A": "Preventable by a live attenuated vaccine", "B": "Original presentation in the form of a painless chancre", "C": "Cause buboes in the inguinal lymph nodes", "D": "Is a common cause of septic arthritis in this patient’s age group"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "Nepal presents", "emergency department", "swelling", "pain", "right testicle", "patient states", "arrived", "United States to live", "wife", "monogamous", "patient denies painful urination", "urethral discharge", "admits", "10 days", "felt", "fever", "right side of", "face", "swollen", "painful", "following", "characteristic", "likely diagnosis"]}
{"question": "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?", "answer": "Sympathetic block", "options": {"A": "Sympathetic block", "B": "Hypovolemia", "C": "Acute pulmonary hypertension", "D": "Aortocaval compression"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old woman", "gravida 2", "para 1", "40 weeks", "gestation", "admitted", "hospital", "active labor", "patient reports severe pelvic pain", "Pregnancy", "complicated", "gestational diabetes", "Pregnancy", "delivery", "first child", "uncomplicated", "Current medications include insulin", "folic acid", "multivitamin", "Vital signs", "normal limits", "cervix", "100", "10", "dilated", "vertex", "at", "1 station", "fetal heart rate", "reactive", "decelerations", "Epidural anesthesia", "performed", "patient's symptoms", "Ten minutes later", "patient", "dizziness", "pulse", "68 min", "respirations", "min", "blood pressure", "90 60 mm Hg", "Intravenous", "begun", "following", "most likely underlying cause", "patient's hypotension"]}
{"question": "A 57-year-old woman is brought to the emergency department by ambulance for dysarthria and left-sided facial droop. She is accompanied by her son, who states that the patient had just returned home an hour ago from walking the dog when suddenly the patient stated she felt “strange.” When her son asked her what was wrong, her speech was slurred and her \"face looked funny.” The son quickly called an ambulance. The paramedic upon arrival noted that the patient had left-sided facial droop. Her medical history includes asthma and sickle cell disease. She takes hydroxyurea, uses oxycodone as needed for pain, and an albuterol inhaler as needed for shortness of breath. The patient’s temperature is 97°F (36.1°C), blood pressure is 145/72 mmHg, pulse is 93/min, and respirations are 14/min with an oxygen saturation of 96% on room air. On physical examination, a left-sided facial droop is appreciated. She has trouble articulating her words, and her speech is garbled. She is put on 2 L of oxygen by nasal cannula. Labs are obtained and pending. Which of the following therapies is most likely indicated?", "answer": "Exchange transfusion", "options": {"A": "Alteplase", "B": "Exchange transfusion", "C": "Hydralazine", "D": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["57 year old woman", "brought", "emergency department", "ambulance", "dysarthria", "left-sided facial droop", "son", "states", "patient", "returned home", "hour", "walking", "dog", "patient stated", "felt", "son", "wrong", "speech", "slurred", "face looked", "son", "called", "ambulance", "paramedic", "arrival noted", "patient", "left-sided facial droop", "medical history includes asthma", "sickle cell disease", "takes hydroxyurea", "uses oxycodone as needed", "pain", "albuterol inhaler as needed", "shortness of breath", "patients temperature", "36", "blood pressure", "72 mmHg", "pulse", "min", "respirations", "14 min", "oxygen saturation", "96", "room air", "physical examination", "left-sided facial droop", "words", "speech", "put", "2", "oxygen", "nasal cannula", "Labs", "obtained", "following therapies", "most likely indicated"]}
{"question": "A 58-year-old male is hospitalized after sustaining multiple fractures in a severe automobile accident. Soon after hospitalization, he develops respiratory distress with crackles present bilaterally on physical examination. The patient does not respond to mechanical ventilation and 100% oxygen and quickly dies due to respiratory insufficiency. Autopsy reveals heavy, red lungs and histology is shown in Image A. Which of the following is most likely to have been present in this patient shortly before death:", "answer": "Interstitial edema", "options": {"A": "Diaphragmatic hypertrophy", "B": "Interstitial edema", "C": "Large pulmonary embolus", "D": "Left apical bronchoalveolar carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["58 year old male", "hospitalized", "sustaining multiple fractures", "severe automobile accident", "hospitalization", "respiratory distress", "crackles present", "physical examination", "patient", "not", "mechanical ventilation", "100", "oxygen", "due to respiratory insufficiency", "Autopsy reveals heavy", "red lungs", "histology", "shown", "Image", "following", "most likely to", "present", "patient", "death"]}
{"question": "A 6-year-old African American boy is referred to the hospital by his family physician for jaundice, normocytic anemia, and severe bone pain. He has a history of several episodes of mild bone pain in the past treated with over the counter analgesics. On physical examination, the child is icteric with nonspecific pain in his hands. His hands are swollen, tender, and warm. There is no chest pain, abdominal pain, fever, or hematuria. A complete metabolic panel and complete blood count with manual differential are performed:\nTotal bilirubin\n8.4 mg/dL\nWBC\n9,800/mm3\nHemoglobin \n6.5 g/dL\nMCV 82.3 fL\nPlatelet count  465,000/mm3\nReticulocyte 7%\nPeripheral blood smear shows multiple clumps of elongated and curved cells and erythrocytes with nuclear remnant. The patient's hemoglobin electrophoresis result is pictured below. What is the most likely cause of his condition?", "answer": "Sickle cell disease", "options": {"A": "Sickle cell trait", "B": "Sickle cell disease", "C": "Hemoglobin F", "D": "HbC"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old African American boy", "referred to", "hospital", "family physician", "jaundice", "normocytic anemia", "severe bone pain", "history of", "episodes", "mild bone pain", "past treated with over the counter analgesics", "physical examination", "child", "icteric", "nonspecific pain", "hands", "hands", "swollen", "tender", "warm", "chest pain", "abdominal pain", "fever", "hematuria", "complete metabolic panel", "complete blood count", "manual differential", "performed", "Total 8.4 mg/dL WBC 9 800 mm3", "5", "MCV", "fL", "count", "Peripheral blood smear shows multiple clumps", "elongated", "curved cells", "erythrocytes", "nuclear remnant", "patient's hemoglobin electrophoresis result", "pictured", "most likely cause", "condition"]}
{"question": "A 55-year-old man presents to the emergency department with complaints of nausea, vomiting, palpitations, and dizziness, which have lasted for the past 3 hours. He was diagnosed with heart failure 1 year ago. During his last visit to his primary care physician, he was doing well and the lab results were normal. He reports that he has been taking low-dose aspirin and digoxin regularly for 1 year, and verapamil was recently added to prevent his frequent migraine headaches. An electrocardiogram is performed urgently and shows paroxysmal atrial tachycardia with block. Suspecting digitalis toxicity, the emergency medicine physician sends blood to the lab for a serum digoxin level, which is 3.7 ng/mL (therapeutic range: 0.8–2 ng/mL). Which of the following mechanisms most likely explains the development of digitalis toxicity in this patient?", "answer": "Inhibition of P-glycoprotein", "options": {"A": "Drug-induced hypokalemia", "B": "Increased intestinal absorption of digoxin", "C": "Inhibition of CYP 3A4 isoenzyme", "D": "Inhibition of P-glycoprotein"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["55 year old man presents", "emergency department", "complaints", "nausea", "vomiting", "palpitations", "dizziness", "lasted", "past", "hours", "diagnosed", "heart failure", "year", "last visit", "primary care physician", "well", "lab results", "normal", "reports", "taking low-dose aspirin", "digoxin", "year", "verapamil", "recently added to prevent", "frequent migraine", "electrocardiogram", "performed", "shows paroxysmal atrial tachycardia with block", "Suspecting digitalis toxicity", "emergency physician sends blood", "lab", "serum digoxin level", "3", "ng/mL", "therapeutic range", "0.82 ng/mL", "following mechanisms", "likely", "development", "digitalis toxicity", "patient"]}
{"question": "A 36-year-old man is brought to the emergency department 25 minutes after being involved in a high speed motor-vehicle collision in which he was an unrestrained passenger. He has acute myeloid leukemia and is currently receiving chemotherapy. On arrival, his temperature is 37°C (98.6°F), pulse is 63/min, respirations are 10/min, and blood pressure is 100/70 mm Hg. The pupils are equal and sluggish. There are multiple bruises over the face, trunk, and right upper and lower extremities. There is a 4-cm (1.6-in) laceration over his right cheek. He does not respond to any commands, but does groan. Painful stimuli cause him to open his eyes and withdraw all extremities. There are decreased breath sounds over the right lung base. There is tenderness to palpation over the left chest wall. Cardiac examination shows no abnormalities. The abdomen is soft and shows diffuse tenderness to palpation with no guarding or rebound. There is swelling of the right elbow and wrist. The right lower extremity is shorter than the left lower extremity. There are 2 lacerations around 2 cm (0.8 in) each on the right leg. The right knee is swollen. Which of the following is the most appropriate next step in management?", "answer": "Intubation and mechanical ventilation", "options": {"A": "Insertion of intercostal chest tube", "B": "CT scan of the head and neck", "C": "X-rays of the extremities", "D": "Intubation and mechanical ventilation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["36 year old man", "brought", "emergency department", "minutes", "involved", "high speed motor-vehicle collision", "passenger", "acute myeloid leukemia", "currently receiving chemotherapy", "arrival", "temperature", "98", "pulse", "63 min", "respirations", "10/min", "blood pressure", "100 70 mm Hg", "pupils", "equal", "sluggish", "multiple bruises", "face", "trunk", "right upper", "lower extremities", "4", "1.6", "laceration", "right cheek", "not", "commands", "Painful stimuli cause", "to open", "eyes", "withdraw", "extremities", "decreased breath sounds", "right lung base", "tenderness", "palpation", "left chest wall", "Cardiac shows", "abnormalities", "abdomen", "soft", "shows diffuse tenderness", "palpation", "guarding", "swelling", "right", "wrist", "right lower extremity", "shorter", "left lower extremity", "2 lacerations", "2", "0.8", "right leg", "right knee", "swollen", "following", "most appropriate next step", "management"]}
{"question": "A 51-year-old woman was recently diagnosed with type II diabetes. Due to the cumulative effects of diabetes, various health screenings and vaccinations are routinely recommended. Which of the following vaccinations or screening measures are recommended in patients with diabetes?", "answer": "Comprehensive foot exam every year", "options": {"A": "Urinalysis every 6 months", "B": "Comprehensive foot exam every year", "C": "Weekly foot inspections by patient or family member", "D": "Meningococcal vaccine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "recently diagnosed", "type II diabetes", "Due to", "cumulative effects", "diabetes", "various health screenings", "vaccinations", "recommended", "following vaccinations", "screening measures", "recommended", "patients", "diabetes"]}
{"question": "A 23-year-old man presents with sudden loss of consciousness while pitching in a baseball game. There is no history of injury. Consciousness is regained after cardiopulmonary resuscitation. Past medical history is negative for any neurological and cardiovascular problems. Physical examination reveals a prominent A wave on the jugular venous pulse and a double apical impulse. There are no audible murmurs. An S4 is present. What is the most likely diagnosis?", "answer": "Hypertrophic cardiomyopathy", "options": {"A": "Hypertrophic cardiomyopathy", "B": "Aortic stenosis", "C": "Takotsubo cardiomyopathy", "D": "Restrictive cardiomyopathy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old man presents", "sudden loss of consciousness", "pitching", "baseball game", "history of injury", "Consciousness", "regained", "cardiopulmonary resuscitation", "Past medical history", "negative", "neurological", "cardiovascular problems", "Physical examination reveals a prominent", "wave", "jugular venous pulse", "double apical impulse", "murmurs", "S4", "present", "most likely diagnosis"]}
{"question": "A 39-year-old man is brought to the emergency department unconscious following 2 episodes of generalized tonic-clonic seizures. According to the attendants, he has complained of recurrent headaches for the past 2 weeks. There is no history of fever, head trauma, or a seizure disorder. The patient does not smoke cigarettes but reportedly drinks 2 glasses of wine daily. He has multiple sexual partners and history regarding the contraceptive use is unavailable. The patient’s vitals include: blood pressure 137/88 mm Hg, temperature 37.2°C (99.0°F). On physical examination, he is obtunded. He grimaces on pain and localizes in response to pain in both upper extremities. Pupils are bilateral 3-mm in diameter and equally round and reactive. Laboratory tests are within normal limits. An MRI of the brain with contrast is shown in the exhibit (see image). A brain biopsy is performed that reveals perivascular clusters of lymphocytes. Which of the following is most associated with this patient’s condition?", "answer": "Epstein-Barr virus", "options": {"A": "Epstein-Barr virus", "B": "Human herpes virus", "C": "Human papilloma virus", "D": "Schistosoma haematobium"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department unconscious following 2 episodes of generalized tonic-clonic seizures", "attendants", "recurrent headaches", "past 2 weeks", "history", "fever", "head trauma", "seizure disorder", "patient", "not smoke cigarettes", "drinks 2 glasses", "wine daily", "multiple sexual partners", "history", "contraceptive use", "unavailable", "patients", "include", "blood pressure", "88 mm Hg", "temperature", "99", "physical examination", "obtunded", "grimaces", "pain", "localizes", "response", "pain", "upper extremities", "Pupils", "bilateral", "mm", "diameter", "round", "reactive", "Laboratory tests", "normal limits", "MRI of", "brain", "contrast", "shown", "exhibit", "see image", "brain biopsy", "performed", "reveals perivascular clusters", "lymphocytes", "following", "most associated with", "patients condition"]}
{"question": "A 22-year-old woman from a rural area who recently discovered she was pregnant is referred for a cardiology consultation due to cyanosis, dyspnea, and a cardiac murmur revealed at the initial prenatal visit. She is gravida 1, para 0 with an estimated gestational age of 19 weeks. She says that the murmur was found in her childhood, and the doctor at that time placed her under observation only. However, she has been lost to follow-up and has not had proper follow up in years. Currently, she complains of dizziness and occasional dyspnea on exertion which has gradually increased during her pregnancy. Prior to her pregnancy, she did not have any symptoms. The vital signs are as follows: blood pressure 125/60 mm Hg, heart rate 81/min, respiratory rate 13/min, and temperature 36.7°C (98.0°F). Her examination is significant for acrocyanosis and a fixed splitting of S2 and grade 3/6 midsystolic murmur best heard over the left upper sternal border. Which of the following physiological pregnancy changes is causing the change in this patient’s condition?", "answer": "Decrease in systemic vascular resistance", "options": {"A": "Increase in heart rate", "B": "Decrease in systemic vascular resistance", "C": "Increase in cardiac output", "D": "Increase in blood volume"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "rural area", "recently discovered", "pregnant", "referred", "cardiology consultation", "cyanosis", "dyspnea", "cardiac murmur revealed", "initial prenatal visit", "gravida 1", "para 0", "estimated gestational age", "19 weeks", "murmur", "found", "childhood", "doctor", "time placed", "observation only", "lost to follow-up", "not", "follow up", "years", "Currently", "dizziness", "occasional dyspnea on exertion", "increased", "pregnancy", "pregnancy", "not", "symptoms", "vital signs", "follows", "blood pressure", "60 mm Hg", "heart rate 81 min", "respiratory rate", "min", "temperature 36", "98", "examination", "significant", "acrocyanosis", "fixed splitting", "S2", "grade", "6 midsystolic murmur best heard", "left upper sternal border", "following physiological pregnancy changes", "causing", "change", "patients condition"]}
{"question": "A 25-year-old man with a past medical history of constipation and fibromyalgia presents to the emergency department with generalized malaise and severe diarrhea. The patient states that he has not felt well for the past 24 hours and his symptoms are no longer tolerable. He denies taking any medications or illicit drugs and states he is generally healthy. His temperature is 99.3°F (37.4°C), blood pressure is 122/88 mmHg, pulse is 107/min, respirations are 19/min, and oxygen saturation is 99% on room air. Physical exam demonstrates an ill appearing young man. Physical exam is notable for rhinorrhea, lacrimation, and piloerection. The patient’s pupils are dilated and reactive to light. During placement of an ultrasound guided IV, multiple scars are noted in the antecubital fossa, and it is noted that it is very difficult to place an IV in this patient. During the exam, he begins actively vomiting. Which of the following could be an appropriate treatment for this patient’s symptoms?", "answer": "Clonidine", "options": {"A": "Clonidine", "B": "Diazepam taper", "C": "Haloperidol and diphenhydramine", "D": "Oseltamivir"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "past medical history of constipation", "fibromyalgia presents", "emergency department", "generalized malaise", "severe diarrhea", "patient states", "not felt well", "past 24 hours", "symptoms", "longer tolerable", "denies taking", "medications", "illicit drugs", "states", "healthy", "temperature", "99", "4C", "blood pressure", "88 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam demonstrates", "ill appearing young man", "Physical exam", "notable", "rhinorrhea", "lacrimation", "piloerection", "patients pupils", "dilated", "reactive to light", "placement", "ultrasound guided IV", "multiple scars", "noted", "antecubital fossa", "noted", "very difficult to place", "IV", "patient", "exam", "begins", "vomiting", "following", "appropriate treatment", "patients symptoms"]}
{"question": "A 45-year-old woman presents to the clinic with her husband to discuss her most recent problem. She and her husband recently bought a new house in the area. While cleaning the house, they discovered a nest of spiders. She reports blacking out and waking up outside the house with a bandage on her arm. Her husband says that she began screaming and ran out of the house, breaking a window, and cutting her arm. The patient says she has tried to enter the house several times over the last several months but can not bring herself to cross the threshold for fear of more spiders. She wants to overcome her extreme and irrational fear. Which of the following is the most effective treatment to overcome this patient’s arachnophobia?", "answer": "Desensitization", "options": {"A": "Desensitization", "B": "Metoprolol", "C": "Alprazolam", "D": "Psychotherapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "clinic", "husband to discuss", "most recent problem", "husband recently bought", "new house", "area", "cleaning", "house", "discovered", "nest", "spiders", "reports blacking out", "waking", "outside", "house", "bandage", "arm", "husband", "began screaming", "ran out", "house", "breaking", "window", "cutting", "arm", "patient", "to enter", "house", "times", "months", "not", "to cross", "threshold", "fear of", "spiders", "to overcome", "extreme", "irrational fear", "following", "most effective treatment to overcome", "patients arachnophobia"]}
{"question": "A 67-year-old man is brought to the physician because of increasing forgetfulness, unsteadiness, and falls over the past year. He reports that these symptoms seem to worsen with each fall. Initially, he could not remember directions to his home but now cannot remember recent conversations or appointments he has made. He often repeats questions that he asked shortly before. He has long-standing hypertension, coronary artery disease, and hypercholesterolemia. Current medications include aspirin, carvedilol, enalapril, and atorvastatin. Examination shows a bruise over the left temple and an unsteady gait. On mental status examination, he is oriented to place and person only. Short-term memory is impaired; he can recall 0 out of 5 objects after 10 minutes. Long-term memory is intact. He has no delusions or hallucinations. Muscle strength is decreased in the left lower extremity. The Babinski sign is present on the left. A CT scan of the head is shown. Which of the following is the most appropriate next step in management?", "answer": "Cognitive training", "options": {"A": "Warfarin therapy", "B": "Vitamin E therapy", "C": "Tetrabenazine therapy", "D": "Cognitive training"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man", "brought", "physician", "increasing forgetfulness", "unsteadiness", "falls", "past year", "reports", "symptoms", "to worsen", "fall", "Initially", "not remember directions", "home", "now", "remember recent conversations", "appointments", "made", "often repeats questions", "long standing hypertension", "coronary artery disease", "hypercholesterolemia", "Current medications include aspirin", "carvedilol", "enalapril", "atorvastatin", "Examination shows", "bruise", "left temple", "unsteady gait", "mental", "oriented to place", "person only", "Short-term memory", "impaired", "recall 0 out", "5 objects", "10 minutes", "Long-term memory", "intact", "delusions", "hallucinations", "Muscle strength", "decreased", "left lower extremity", "Babinski sign", "present", "left", "CT scan of", "head", "shown", "following", "most appropriate next step", "management"]}
{"question": "A 28-year-old primigravid woman at 39 weeks gestation is admitted to the hospital in active labor. On examination, the cervix is 100% effaced and 10 cm dilated. After 5 minutes of pushing, there is a prolonged deceleration of the fetal heart rate to 90/min. A decision to perform an episiotomy is made to expedite vaginal delivery. The anesthesiologist locates the ischial spines by palpating the posterolateral vaginal sidewall and administers an anesthetic. Three minutes later, pinching the posterior vulva does not provoke pain. The anesthetized nerve most likely also supplies which of the following structures?", "answer": "External anal sphincter", "options": {"A": "Skin of the lateral thigh", "B": "External anal sphincter", "C": "Skin of the mons pubis", "D": "Detrusor muscle"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old primigravid woman", "weeks", "admitted", "hospital", "active labor", "examination", "cervix", "100", "10", "dilated", "5 minutes", "pushing", "prolonged deceleration", "fetal heart rate", "90 min", "decision to perform", "episiotomy", "made to expedite vaginal delivery", "anesthesiologist locates", "ischial spines", "palpating", "posterolateral vaginal", "administers", "anesthetic", "Three minutes later", "pinching", "posterior vulva", "not", "pain", "anesthetized nerve", "likely", "supplies", "following structures"]}
{"question": "A 55-year-old woman with a history of HIV presents to the emergency department with progressive dyspnea, fever, and dry cough for the past 4 days. She has not been compliant with antiretroviral or prophylactic medication. On evaluation, the patient is in moderate respiratory distress. The temperature is 38.8°C (102.0°F), the blood pressure is 124/82 mm Hg, the pulse is 96/min, and the respiratory rate is 20/min. Pulse oximetry is 92% on 4 L oxygen by nasal cannula. Her CD4 count is 180 cells/μL. IV antibiotics and glucocorticoids are administered. After 30 minutes, the patient develops severe respiratory distress. Repeat vital signs show: temperature 38.3°C (101.0°F), blood pressure 80/50 mm Hg, pulse 104/min, respiration rate 32/min and pulse oximetry 85% on nasal cannula. The trachea deviates to the left. Breath sounds are absent on the right side and the neck veins are distended. Telemetry shows sinus tachycardia. Which of the following is the best next step in the management of this patient?", "answer": "Needle thoracostomy", "options": {"A": "Discontinue antibiotics", "B": "Perform an arterial blood gas", "C": "Needle thoracostomy", "D": "Stat chest X-ray"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["55 year old woman", "history", "HIV presents", "emergency department", "progressive dyspnea", "fever", "dry cough", "past 4 days", "not", "compliant", "antiretroviral", "prophylactic medication", "evaluation", "patient", "moderate respiratory distress", "temperature", "blood pressure", "mm Hg", "pulse", "96 min", "respiratory rate", "20 min", "Pulse oximetry", "oxygen", "nasal cannula", "CD4 count", "cells/L", "IV antibiotics", "glucocorticoids", "administered", "30 minutes", "patient", "severe respiratory distress", "Repeat vital signs show", "temperature", "3C", "blood pressure 80 50 mm Hg", "pulse", "min", "respiration rate", "min", "pulse oximetry 85", "nasal cannula", "trachea deviates", "left", "Breath sounds", "absent", "right side", "neck veins", "distended", "Telemetry shows sinus tachycardia", "following", "best next step", "management", "patient"]}
{"question": "A 22-year-old woman with polycystic ovarian syndrome comes to the emergency department because of a 1-day history of left lower abdominal pain that began suddenly while she was running. Her last menstrual period was 2 weeks ago. Physical examination shows tenderness to palpation over the left adnexa and rebound tenderness in the left lower quadrant. There is no tenderness in the right lower quadrant. Urine pregnancy test is negative. An ultrasound is ordered to confirm the diagnosis of ruptured ovarian cyst. Visualization of fluid in which of the following locations would be most consistent with this diagnosis?", "answer": "Rectouterine pouch", "options": {"A": "Rectouterine pouch", "B": "Hepatorenal space", "C": "Splenorenal angle", "D": "Rectovesical pouch"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "polycystic ovarian syndrome", "emergency department", "1-day history", "left lower abdominal pain", "began", "running", "last menstrual period", "2 weeks", "Physical examination shows tenderness", "palpation", "left adnexa", "rebound tenderness", "left lower quadrant", "tenderness", "right lower quadrant", "Urine pregnancy test", "negative", "ultrasound", "ordered to confirm the diagnosis of ruptured ovarian cyst", "Visualization", "fluid", "following locations", "most consistent with", "diagnosis"]}
{"question": "A 47-year-old woman comes to the physician for a follow-up examination. She has noticed trembling of her hands for the past 5 months. These movements are only present when she reaches to pick up an object or answer the phone. She has a history of major depressive disorder but has been off medications for the past 3 years. Her father had Parkinson's disease and died 6 months ago. She drinks a glass of wine daily. She appears anxious. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 118/74 mm Hg. A low-frequency tremor is present that worsens as she reaches out for an object. She consistently overshoots her target. There is no tremor present when her arms are held outstretched. There is increased tone in the lower extremities and Babinski's sign is positive bilaterally. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Cerebellar demyelination", "options": {"A": "Cerebellar demyelination", "B": "Degenerated substantia nigra", "C": "Degenerated caudate nucleus", "D": "Subthalamic nucleus stroke\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up examination", "trembling", "hands", "past", "months", "movements", "only present", "reaches to pick", "object", "answer", "phone", "history of major depressive disorder", "medications", "past", "years", "father", "Parkinson's disease", "died", "months", "drinks", "glass", "wine daily", "appears anxious", "temperature", "98", "pulse", "80 min", "blood pressure", "74 mm Hg", "low-frequency tremor", "present", "worsens", "reaches out", "object", "target", "tremor present", "arms", "held", "increased tone", "lower extremities", "Babinski's sign", "positive", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 52-year-old man comes to the physician because of generalized pruritus and raised, erythematous plaques on the skin over his hands, chest, and legs for 6 hours. He reports having clear liquid discharge from his nose and sneezing. He says that his symptoms began suddenly the previous night, 30 minutes after he had dinner at a seafood restaurant. He has had similar symptoms occasionally in the past as well. Four months ago, he had an episode of narrow-angle glaucoma. He takes no medications. His vital signs are within normal limits. Nasal exam shows clear, serous secretions, with edematous and erythematous mucosa and turbinates. Paranasal sinuses are not tender to palpation. Which of the following is the most appropriate pharmacotherapy?", "answer": "Fexofenadine", "options": {"A": "Diphenhydramine", "B": "Fexofenadine", "C": "Vitamin K", "D": "Calamine lotion"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "generalized pruritus", "raised", "erythematous", "skin", "hands", "chest", "legs", "hours", "reports", "clear liquid discharge from", "nose", "sneezing", "symptoms began", "previous night", "30 minutes", "dinner", "seafood restaurant", "similar symptoms occasionally", "past", "well", "Four months", "episode of narrow-angle glaucoma", "takes", "medications", "vital signs", "normal limits", "Nasal exam shows clear", "serous secretions", "edematous", "erythematous mucosa", "turbinates", "Paranasal sinuses", "not tender", "palpation", "following", "most appropriate pharmacotherapy"]}
{"question": "A 19-year-old man in a 3-month relationship with a woman experiences frequent sexual fantasies about male coworkers. He lives in a conservative community and does not know any openly gay men. Two days ago, he joined a local group considered by many organizations to be a hate group. Together with the other members, he attacked a gay couple on their way home from dinner. Which of the following psychological defense mechanisms is he demonstrating?", "answer": "Reaction formation", "options": {"A": "Sublimation", "B": "Reaction formation", "C": "Intellectualization", "D": "Projection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "3 month relationship", "woman experiences frequent sexual fantasies", "male coworkers", "lives in a", "community", "not", "gay men", "Two days", "local group considered", "organizations to", "hate group", "members", "attacked", "gay couple", "home", "dinner", "following psychological defense mechanisms"]}
{"question": "A 66-year-old woman presents to her primary care provider with several days of left flank pain radiating to the abdomen and groin. The patient states that she has noticed a pink tinge to her urine as well. Of note, she has not had any fevers, but endorses several months of fatigue and constipation. The patient was previously healthy except for mild untreated hypertension. On exam, her temperature is 98.6°F (37.0°C), blood pressure is 130/84 mmHg, pulse is 76/min, and respirations are 12/min. On further workup, the patient is found to have calcium oxalate nephrolithiasis with hypercalciuria. Blood studies demonstrate increased parathyroid hormone (PTH) and hypercalcemia. Which of the following is the most likely cause?", "answer": "Primary hyperparathyroidism", "options": {"A": "Primary hyperparathyroidism", "B": "Pseudopseudohypoparathyroidism", "C": "Secondary hyperparathyroidism", "D": "Tertiary hyperparathyroidism"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old woman presents", "primary care provider", "several days", "left flank pain radiating", "abdomen", "groin", "patient states", "pink", "urine", "well", "note", "not", "fevers", "several months", "fatigue", "constipation", "patient", "healthy", "mild untreated", "exam", "temperature", "98", "blood pressure", "84 mmHg", "pulse", "76 min", "respirations", "min", "further workup", "patient", "found to", "calcium oxalate nephrolithiasis", "hypercalciuria", "Blood studies", "increased parathyroid hormone", "hypercalcemia", "following", "most likely cause"]}
{"question": "A 23-year-old woman presents to her psychiatrist concerned about her mood. She has felt tired and unwilling to engage in any activities lately. She states that her limbs feel heavy all the time and that completing any activity takes tremendous effort. She no longer finds any happiness in activities that she previously enjoyed. She also states that she really struggles to sleep and at times can't sleep for several days. The patient is started on appropriate first-line therapy and sent home. She returns 1 week later stating that her symptoms have not improved. She is requesting help as her performance at work and school is suffering. Which of the following is the best next step in management?", "answer": "Continue current therapy", "options": {"A": "Add lithium to treatment regimen", "B": "Change treatment to lithium", "C": "Continue current therapy", "D": "Electroconvulsive therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["23 year old woman presents", "psychiatrist concerned", "mood", "felt tired", "unwilling", "activities", "states", "limbs feel heavy", "time", "completing", "activity takes", "effort", "longer finds", "happiness", "activities", "enjoyed", "states", "to sleep", "times", "sleep", "days", "patient", "started", "appropriate first-line therapy", "sent home", "returns 1 week later stating", "symptoms", "not improved", "requesting help", "performance", "work", "school", "suffering", "following", "best next step", "management"]}
{"question": "A 16-year-old patient presents to the physician’s office with an absence of menstruations. Her last period was 6 months ago. Since almost a year and a half ago, she intentionally restricted her diet at the expense of carbohydrates, exercised intensively, and lost 18.0 kg (39.7 lb). She had her menarche at the age of 12 and menstruated normally until last year. She is not sexually active. On physical examination, the vital signs include blood pressure 100/60 mm Hg, heart rate 55/min, respiratory rate 12/min, and temperature 35.9°C (96.6°F). Her weight is 55.0 kg (121.3 lb), and her height is 166 cm (5 ft 5 in). Physical examination reveals the good development of muscles and decreased adiposity. A bone scan shows decreased calcium mineral deposits. Which statement about this patient’s condition is correct?", "answer": "Decreased adiposity contributes to hypoestrogenemia in this patient", "options": {"A": "This patient has insulin resistance", "B": "Decreased adiposity contributes to hypoestrogenemia in this patient", "C": "The patient is likely to have decreased blood estrogen concentration due to increased liver metabolism", "D": "The patient should be checked for hyperthyroidism because such extensive lipolysis is likely to result from thyroid hyperfunction"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old patient presents", "physicians office", "absence of menstruations", "last period", "months", "almost", "year", "half", "restricted", "diet", "expense", "carbohydrates", "exercised", "lost", "0 kg", "menarche at", "age", "last year", "not sexually active", "physical examination", "vital signs include blood pressure 100 60 mm Hg", "heart rate 55 min", "respiratory rate", "min", "temperature 35", "96", "weight", "55 0 kg", "height", "5 ft 5", "Physical examination reveals", "good development", "muscles", "decreased adiposity", "bone scan shows decreased calcium mineral deposits", "statement", "patients condition", "correct"]}
{"question": "A 7-year-old girl is brought to the emergency department with a 10-day history of fever and sore throat that acutely worsened over the past 2 days. Her sore throat is worse on the right side. She has difficulty swallowing and opening her mouth due to pain. She has also noticed a change in the quality of her voice over the last day. Her temperature is 38.2°C (100.8°F), pulse is 86/min, respirations are 18/min, and blood pressure is 110/75 mm Hg . Examination shows cervical lymphadenopathy. Oropharyngeal examination shows erythematous tonsils and swelling of the right tonsillar pillar. The uvula is deviated to the left. Laboratory studies show:\nHemoglobin 13.0 g/dL\nHematocrit 39%\nLeukocyte count 12,000/mm3\nPlatelet Count 200,000/mm3\nSerum\nNa+ 138 mEq/L\nCl- 100 mEq/L\nK+ 4.5 mEq/L\nHCO3- 24 mEq/L\nUrea nitrogen 14.0 mg/dL\nCreatinine 1.1 mg/dL\nWhich of the following is the most appropriate next step in management?\"", "answer": "Incision and drainage with intravenous ampicillin-sulbactam therapy", "options": {"A": "Intravenous dexamethasone therapy", "B": "Incision and drainage with intravenous ampicillin-sulbactam therapy", "C": "Needle aspiration and oral clindamycin therapy", "D": "Intravenous ampicillin-sulbactam therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "emergency department", "a 10 day history", "fever", "sore throat", "worsened", "past 2 days", "sore throat", "worse", "right side", "difficulty swallowing", "opening", "mouth due to pain", "change", "quality", "voice", "last day", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "75 mm Hg", "Examination shows cervical lymphadenopathy", "Oropharyngeal examination shows erythematous tonsils", "swelling of", "right tonsillar", "uvula", "deviated", "left", "Laboratory studies show", "Hemoglobin", "Hematocrit 39", "Leukocyte count", "mm3 Platelet Count", "Cl", "100", "HCO3", "mg", "mg", "following", "most appropriate next step", "management"]}
{"question": "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:\nHemoglobin 7.5 g/dL\nMean corpuscular volume 89 μm3\nReticulocyte count 13.3%\nSerum\nSodium 139 mEq/L\nPotassium 3.9 mEq/L\nCalcium 8.5 mg/dL\nTest of the stool for occult blood is negative. Abdominal ultrasonography show no abnormalities. Which of the following is the most likely diagnosis?\"", "answer": "Factitious disorder", "options": {"A": "Factitious disorder", "B": "Somatic symptom disorder", "C": "Conversion disorder", "D": "Acute small bowel hemorrhage"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old nurse", "physician", "2 month history", "fatigue", "lot", "stress", "work", "sick leave", "2 weeks", "states", "to return to work", "several episodes of lower abdominal pain", "I", "I", "cancer", "requests", "diagnostic laparoscopy", "diagnosed", "peptic ulcer disease", "months", "only medication", "omeprazole", "patient appears pale", "temperature", "36", "97", "F", "pulse", "min", "blood pressure", "90 65 mm Hg", "mental", "tired", "depressed mood", "Physical examination shows pale conjunctivae", "dry mucous membranes", "numerous crusts", "course", "left", "grade", "systolic ejection murmur", "heard", "right upper sternal border", "Abdominal examination shows", "abnormalities", "generalized weakness", "proximal muscles", "Laboratory studies show", "Hemoglobin", "g", "Mean corpuscular volume", "Reticulocyte count", "Serum Sodium", "mEq", "mg", "Test", "stool", "occult blood", "negative", "Abdominal ultrasonography show", "abnormalities", "following", "most likely diagnosis"]}
{"question": "Five days after undergoing an emergency appendectomy under general inhalational anesthesia while on a trip to Haiti, a 43-year-old woman develops low-grade fever, vomiting, and abdominal pain. During the surgery, she received a transfusion of 1 unit of packed red blood cells. Three days after the surgery, she was stable enough to be transported back to the United States. She has no history of serious illness and takes no medications. Her temperature is 38.3°C (100.9°F), pulse is 80/min, and blood pressure is 138/76 mm Hg. Examination shows jaundice of the skin and conjunctivae. Abdominal examination shows moderate tenderness over the liver. The liver is palpated 2 to 3 cm below the right costal margin. Laboratory studies show:\nHemoglobin count 12.0 g/dL\nLeukocyte count 10,400 mm3\nSegmented neutrophils 55%\nBands 1%\nEosinophils 13%\nLymphocytes 28%\nMonocytes 3%\nPlatelet count 160,000 mm3\nSerum\nAlkaline phosphatase 102 U/L\nAspartate aminotransferase 760 U/L\nBilirubin\nTotal 3.8 mg/dL\nDirect 3.1 mg/dL\nAnti-HAV IgG positive\nAnti-HAV IgM negative\nAnti-HBs positive\nHBsAg negative\nAnti-HCV antibodies negative\nAbdominal ultrasonography shows an enlarged liver. A biopsy of the liver shows massive centrilobular necrosis. Which of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Adverse effect of anesthetic", "options": {"A": "Adverse effect of anesthetic", "B": "Gram negative bacteria in the bloodstream", "C": "Acalculous inflammation of the gallbladder", "D": "Excessive lysis of red blood cells"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Five days", "emergency appendectomy", "general inhalational anesthesia", "trip", "Haiti", "year old woman", "low-grade fever", "vomiting", "abdominal pain", "surgery", "received", "transfusion of", "packed red blood cells", "Three days", "surgery", "stable", "to", "transported back", "United States", "history", "serious illness", "takes", "medications", "temperature", "3C", "100 9F", "pulse", "80 min", "blood pressure", "76 mm Hg", "Examination shows jaundice", "skin", "conjunctivae", "Abdominal examination shows moderate tenderness", "liver", "liver", "palpated 2", "3 cm", "right costal margin", "Laboratory studies show", "dL Leukocyte", "mm3 Segmented", "Bands", "Eosinophils", "Platelet count", "Alkaline phosphatase", "Aspartate aminotransferase", "Total", "dL Direct 3.1 mg/dL Anti IgG positive", "IgM negative", "HBs", "HBsAg", "HCV antibodies", "Abdominal ultrasonography shows", "enlarged liver", "biopsy of", "liver shows massive centrilobular necrosis", "following", "most likely underlying cause", "patient", "ondition?"]}
{"question": "A 56-year-old woman comes to the physician because of a 2-week history of fatigue and painless bruising over her arms and trunk. She has also had several episodes of nosebleeds that resolved with compression after a few minutes. She recently completed treatment for a urinary tract infection. She has had no changes in her weight. She has type 2 diabetes mellitus and hypertension. Her last menstrual cycle was 5 years ago. She does not smoke or drink alcohol. Home medications include metformin, amlodipine, and enalapril. Her vital signs are within normal limits. Physical examination shows pale conjunctivae. There are ecchymoses and petechiae over the upper extremities, chest, and back. There is no lymphadenopathy. The remainder of the physical examination is unremarkable. Laboratory studies show:\nHemoglobin 8.7 mg/dL\nLeukocyte count 1100/mm3\nPlatelet count 54,000/mm3\nReticulocyte count 0.1%\nMean corpuscular volume 93 μm3\nSerum\nTotal bilirubin 1.1 mg/dL\nLDH 80 U/L\nWhich of the following is most likely to confirm the diagnosis?\"", "answer": "Bone marrow biopsy", "options": {"A": "Serum transferrin level", "B": "Bone marrow biopsy", "C": "Peripheral blood smear", "D": "Serum porphobilinogen level"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "2-week history", "fatigue", "painless bruising", "arms", "trunk", "several episodes of nosebleeds", "resolved", "compression", "few minutes", "recently completed treatment", "urinary tract infection", "changes in", "weight", "type 2 diabetes mellitus", "hypertension", "last menstrual cycle", "5 years", "not smoke", "drink alcohol", "Home medications include metformin", "amlodipine", "enalapril", "vital signs", "normal limits", "Physical examination shows pale conjunctivae", "ecchymoses", "petechiae", "upper extremities", "chest", "back", "lymphadenopathy", "physical examination", "unremarkable", "Laboratory studies show", "Hemoglobin", "mg Leukocyte", "mm3 Platelet 54", "Reticulocyte", "Mean", "m3 Serum Total bilirubin", "dL", "80", "L", "following", "most likely to confirm", "diagnosis"]}
{"question": "A 35-year-old man returns to the clinic to follow up for his chronic stomach pain. At the last visit a few months ago, he explained that he had been experiencing discomfort in his upper abdomen for awhile. He had never vomited up any blood and had not had any substantial weight loss. He did not take any medications, did not smoke, and had no family history of gastric cancer. At that time, the doctor empirically started him on a proton pump inhibitor (PPI). Today, despite the PPI, the patient says he is still experiencing discomfort. Hearing this, the doctor decides to order a urease breath test. What is the most likely cause of this patient's chronic stomach pain?", "answer": "Heliobacter pylori infection", "options": {"A": "Gastroesophgeal sphincter dysfunction", "B": "Nonsteroidal anti-inflammatory drugs", "C": "Heliobacter pylori infection", "D": "Excessive gastrin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["35 year old man returns", "clinic to follow up", "chronic stomach", "last visit", "few months", "experiencing discomfort", "upper", "never vomited", "blood", "not", "weight loss", "not take", "medications", "not smoke", "family history of gastric cancer", "time", "doctor", "started", "proton pump inhibitor", "Today", "PPI", "patient", "experiencing discomfort", "Hearing", "doctor", "to order", "urease breath", "most likely cause", "patient's chronic stomach"]}
{"question": "A 32-year-old G1P1 patient presents to her obstetrician after having a positive pregnancy test at home. She reports that she and her husband had been trying to have a child for the past three months. She has no history of sexually transmitted disease, intravenous drug use, or blood transfusions, and she has never traveled outside of the United States. She was up-to-date on all immunizations before her pregnancy. Ultrasound is consistent with an 8-week gestational sac. The patient requests as few tests as possible, although she does not want to compromise the health of her fetus. Which of the following screening tests should be performed on all pregnant women?", "answer": "HIV, syphilis, and hepatitis B", "options": {"A": "HIV, syphilis, and hepatitis B", "B": "HIV, syphilis, and N. gonorrhea", "C": "HIV, hepatitis B, and hepatitis C", "D": "HIV, syphilis, hepatitis B, N. gonorrhea, and C. trachomatis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old G1P1 patient presents", "obstetrician", "positive pregnancy test at home", "reports", "husband", "to", "child", "past three months", "history of sexually transmitted disease", "intravenous drug use", "blood transfusions", "never traveled outside of", "United States", "date", "immunizations", "pregnancy", "Ultrasound", "consistent with", "week gestational sac", "patient requests", "tests", "possible", "not", "to compromise", "health", "fetus", "following screening tests", "performed", "pregnant women"]}
{"question": "A 29-year-old man is referred by his marriage counselor to the outpatient psychiatry clinic. The patient’s wife is with him and states that her husband is always complaining and critical of others. He was recently fired from his job to which he claims that his boss was jealous of his hard work. He also does not trust his neighbors and thinks they are out to get all the nice things he has. His wife also says that he has begun to doubt her fidelity and believes that even the marriage counselor is on her side. Which of the following psychiatric disorders also belongs to the same cluster of symptoms?", "answer": "Schizotypal personality disorder", "options": {"A": "Schizotypal personality disorder", "B": "Obsessive-compulsive personality disorder", "C": "Antisocial personality disorder", "D": "Personality disorder not otherwise specified"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old man", "referred", "marriage counselor", "outpatient psychiatry", "patients wife", "states", "husband", "always", "critical", "others", "recently fired", "job", "boss", "jealous", "hard work", "not trust", "neighbors", "thinks", "out to", "nice things", "wife", "begun to doubt", "fidelity", "marriage counselor", "side", "following psychiatric disorders", "same cluster", "symptoms"]}
{"question": "A 24-year-old man is brought to the emergency department by the police. He was found unconscious and covered in bruises outside of a local bar. The patient has a past medical history of polysubstance abuse, depression, multiple suicide attempts, neuropathic pain, and schizophrenia. As part of the patient’s initial workup, a head CT is performed which is unremarkable, and an arterial blood gas is performed as seen below:\n\npH: 7.29\nPaCO2: 95 mm Hg\nPaO2: 70 mm Hg\nBicarbonate: 24 mEq/L\n\nWhich of the following is the most likely etiology of this patient’s current presentation?", "answer": "Heroin", "options": {"A": "Amitriptyline", "B": "Cocaine", "C": "Ethylene glycol", "D": "Heroin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "police", "found unconscious", "covered", "bruises", "local", "patient", "past medical polysubstance abuse", "depression", "multiple suicide attempts", "neuropathic pain", "schizophrenia", "part of", "patients initial workup", "head CT", "performed", "unremarkable", "arterial blood gas", "performed", "seen", "pH", "29", "95 mm Hg PaO2", "70 mm Hg Bicarbonate", "mEq/L", "following", "most likely etiology", "patients current presentation"]}
{"question": "A 3-year-old girl is brought to the emergency department by her parents for an acute arm injury. The mother reports that they were walking in the park and the patient’s dad was swinging the patient in the air by her arms. The dad reports he then heard a click and the patient immediately began to cry. On examination, the patient is holding her right forearm in a pronated position and her elbow slightly flexed. Pain is localized to the lateral aspect of the elbow. She refuses to use the affected limb. She does allow passive flexion and extension with full range of motion but supination is limited and causes pain. Which of the following is the next step in management?", "answer": "Moderate flexion then hyperpronation", "options": {"A": "Immobilization", "B": "Moderate flexion then hyperpronation", "C": "Radiograph", "D": "Supination then maximal extension"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 year old girl", "brought", "emergency department", "parents", "acute arm injury", "mother reports", "walking in", "park", "patients dad", "patient", "air", "arms", "dad reports", "then heard", "patient immediately began", "cry", "examination", "patient", "holding", "right forearm", "position", "elbow slightly flexed", "Pain", "localized", "lateral aspect", "elbow", "refuses to use", "affected limb", "allow passive flexion", "extension", "full range of motion", "supination", "limited", "causes pain", "following", "next step", "management"]}
{"question": "A 40-year-old male presents to your office complaining that he is too weak to climb stairs or brush his hair. He denies any headaches or change in vision. A muscle biopsy reveals CD8+ lymphocyte infiltration in the endomysium. Which of the following is the most likely diagnosis?", "answer": "Polymyositis", "options": {"A": "Systemic lupus erythematosus", "B": "Polymyalgia rheumatica", "C": "Polymyositis", "D": "Dermatomyositis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old male presents", "office", "weak", "climb stairs", "brush", "hair", "denies", "headaches", "change", "vision", "muscle biopsy reveals CD8", "lymphocyte infiltration", "endomysium", "following", "most likely diagnosis"]}
{"question": "A 6-month-old boy presents to his pediatrician for a wellness examination. The mother reports that her child has difficulty rolling from his back to his front and sitting unsupported. The patient is able to smile and furrow his brow normally, but she has noticed that he has a weak cry and suck. He was born at 38 weeks gestation via a spontaneous vaginal delivery without any complications. The mother said that the patient appeared \"normal\" until the past few weeks. On physical exam, his extraocular muscle movements are intact, and a symmetric smile is seen. He has symmetric flaccid weakness of both his upper and lower extremities. He also has a bell-shaped chest. Deep tendon reflexes are diminished. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Anterior horn cell degeneration", "options": {"A": "Anterior horn cell degeneration", "B": "Axonal demyelination", "C": "Decreased acetylcholine receptor density", "D": "Myonecrosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["month old boy presents", "pediatrician", "wellness examination", "mother reports", "child", "difficulty rolling", "back", "front", "sitting", "patient", "able", "smile", "furrow", "weak cry", "suck", "born", "weeks gestation", "spontaneous vaginal delivery", "complications", "mother", "patient appeared", "normal", "past", "weeks", "physical exam", "extraocular muscle movements", "intact", "symmetric smile", "seen", "symmetric flaccid weakness", "upper", "lower extremities", "bell-shaped chest", "Deep tendon reflexes", "diminished", "following", "most likely cause", "patient", "ymptoms?"]}
{"question": "A 6-day-old male newborn is brought to the physician because he has become increasingly irritable and restless over the past 2 days. During this period, he has had 12 bowel movements. He feeds 10 to 12 times a day. He was born at 38 weeks' gestation and weighed 1800 g (3 lb 15 oz); he currently weighs 1700 g (3 lb 12 oz). His mother has Graves' disease and received propylthiouracil during the last trimester of pregnancy. She has a history of intravenous heroin use. His temperature is 36.9°C (98.4°F), pulse is 180/min, and respirations are 50/min. Examination shows mild diaphoresis and a firm 2-cm midline neck swelling. The lungs are clear to auscultation. Which of the following is the most appropriate next step in management?", "answer": "Methimazole and propranolol therapy", "options": {"A": "Methimazole and propranolol therapy", "B": "Potassium iodide therapy", "C": "Naloxone therapy", "D": "Calcium gluconate therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["day old male newborn", "brought", "physician", "irritable", "restless", "past 2 days", "period", "bowel movements", "feeds 10", "times", "day", "born", "weeks", "gestation", "g", "oz", "currently", "g", "oz", "mother", "Graves", "disease", "received propylthiouracil", "last trimester", "pregnancy", "history of intravenous heroin use", "temperature", "36", "98 4F", "pulse", "min", "respirations", "50 min", "Examination shows mild diaphoresis", "firm", "midline neck swelling", "lungs", "clear", "auscultation", "following", "most appropriate next step", "management"]}
{"question": "A previously healthy 29-year-old man comes to the emergency department because of burning with urination for several days. He has also had pain in the right ankle for 3 days and pain and swelling in the left knee for 1 day. Two weeks ago, he had several days of fever and bloody diarrhea, for which he was treated with antibiotics. Examination shows a small left knee effusion and bilateral conjunctival injection. Which of the following is the most likely additional finding in this patient?", "answer": "Tenderness at the insertion of the Achilles tendon", "options": {"A": "Circular erythematous rash with central clearing", "B": "Pain on passive extension of the fingers", "C": "Palpable mass in the right lower quadrant", "D": "Tenderness at the insertion of the Achilles tendon"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy 29 year old man", "emergency department", "of burning", "urination", "several days", "pain in", "right ankle", "3 days", "pain", "swelling in the left knee", "1 day", "Two weeks", "several days", "fever", "bloody diarrhea", "treated with antibiotics", "Examination shows", "small left knee effusion", "bilateral conjunctival injection", "following", "most likely additional finding", "patient"]}
{"question": "A 36-year-old woman comes to the physician because of a painless lump on her neck for 3 months that has increased in size. She appears healthy. Examination shows a 2.5-cm (1-in) firm, irregular swelling on the left side of the neck that moves with swallowing. There is painless cervical lymphadenopathy. Ultrasound of the neck shows a solitary left lobe thyroid mass with increased vascularity and hyperechogenic punctate regions. A fine needle aspiration biopsy is scheduled for the following week. Which of the following is the most likely diagnosis?", "answer": "Papillary carcinoma of the thyroid", "options": {"A": "Follicular carcinoma of the thyroid", "B": "Hürthle cell carcinoma of the thyroid", "C": "Papillary carcinoma of the thyroid", "D": "Anaplastic carcinoma of the thyroid"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old woman", "physician", "of", "painless lump on", "neck", "3 months", "increased in size", "appears healthy", "Examination shows", "2.5", "1", "firm", "irregular swelling", "the left side of", "neck", "moves", "swallowing", "painless cervical lymphadenopathy", "Ultrasound of the neck shows", "solitary left lobe thyroid mass", "increased vascularity", "punctate regions", "fine needle aspiration biopsy", "scheduled", "following week", "following", "most likely diagnosis"]}
{"question": "A 34-year-old man currently staying at an addiction center presents to the staff psychiatrist with diarrhea and painful muscle cramps. He has been discontinuing heroin over the last month as part of his treatment plan. He is HIV positive, hepatitis B (HBV) positive, and was recently treated for an infection with Streptococcus pneumoniae. He reports pain over his abdomen, knees, and shoulder. To comprehensively treat these symptoms, which of the following would be the best therapy?", "answer": "Methadone", "options": {"A": "Methadone", "B": "Naloxone", "C": "Alvimopan", "D": "Loperamide"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man currently", "addiction center presents", "staff psychiatrist", "diarrhea", "painful muscle cramps", "discontinuing heroin", "month", "part of", "treatment plan", "HIV positive", "hepatitis B", "positive", "recently treated", "infection", "Streptococcus pneumoniae", "reports pain", "abdomen", "knees", "shoulder", "treat", "symptoms", "following", "best therapy"]}
{"question": "A 26-year-old man presents to his physician with a history of diarrhea and vomiting for the past 24 hours. On physical examination, his temperature is 36.9ºC (98.4ºF), pulse rate is 110/min, blood pressure is 102/74 mm Hg, and respiratory rate is 16/min. A resident working under the physician plots a Darrow-Yannet diagram for the patient. The diagram is shown in the picture where the green dotted line represents the new fluid status. Which of the following is most likely to show increased secretion in this patient?", "answer": "Renin", "options": {"A": "B-type natriuretic peptide", "B": "Bradykinin", "C": "Renin", "D": "Vasoactive intestinal peptide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "history", "diarrhea", "vomiting", "past 24 hours", "physical examination", "temperature", "36", "98 4F", "pulse rate", "min", "blood pressure", "74 mm Hg", "respiratory rate", "min", "resident working", "physician", "diagram", "patient", "diagram", "shown", "picture", "green", "line represents", "new fluid status", "following", "most likely to show increased secretion", "patient"]}
{"question": "A 28-year-old female comes to the physician’s office with a complaint of episodic chest pain. She describes the pain as squeezing and tightness in her chest. This pain has been happening every few days for 3 months. She says there is no association of the pain with food or exercise. She is able to climb up to her fourth floor apartment daily without issue. Her only past medical history is migraines for which she takes appropriate medication. Here temperature is 98.6°F (37°C), blood pressure is 120/68 mmHg, pulse is 60/min, respirations are 16/min, and oxygen saturation is 98% on room air. She has no known family history. The patient is not in pain on presentation and EKG in the office is normal. 24-hour ECG monitoring shows transient ST elevations during the episodes of pain that resolve completely. The mechanism of this patient’s chest pain is most similar to the mechanism behind which of the following?", "answer": "Raynaud's phenomenon", "options": {"A": "Raynaud's phenomenon", "B": "Myocardial infarction", "C": "Aortic dissection", "D": "Costochondritis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "physicians office", "complaint of episodic chest pain", "pain", "squeezing", "tightness in", "chest", "pain", "few days", "months", "association", "pain", "food", "exercise", "able to climb up to", "fourth floor apartment daily", "issue", "only past medical history", "migraines", "takes appropriate medication", "temperature", "98", "blood pressure", "68 mmHg", "pulse", "60 min", "respirations", "min", "oxygen saturation", "98", "room air", "known family history", "patient", "not", "pain", "presentation", "EKG", "office", "normal", "24-hour ECG monitoring shows transient ST elevations", "episodes of pain", "resolve completely", "mechanism of", "patients chest pain", "most similar", "mechanism", "following"]}
{"question": "A 22-year-old gravida 1 presents to her physician at 15 weeks gestation for a prenatal appointment. She complains of a rash involving her chest, face, and arms, a watery nasal discharge, and mild bilateral knee pain. She has had these symptoms for about 5 days. The symptoms do not seem to bother her too much, but she is concerned for the baby. She had contact with her younger sister, who also had a rash and was diagnosed with rubella infection about 10 days ago at a family gathering. She cannot confirm her vaccination history. Her vital signs are as follows: blood pressure, 110/70 mmHg; heart rate, 89/min; respiratory rate, 12/min; and temperature, 37.6℃ (99.7℉). Examination shows a moderately dense maculopapular lacy rash spread over the patient’s trunk, extremities, and face. No lymph node, liver, or spleen enlargement is noted. The knee joints appear normal.\nSerology performed 1 year ago Current serology\nRubella IgM - negative Rubella IgM - negative\nRubella IgG - 1:128 Rubella IgG - 1:64\nRubella IgG avidity - high Rubella IgG avidity - high\nWhat is the proper next step in the management of this woman?", "answer": "Recommend additional serologic testing for parvovirus B19", "options": {"A": "Reassure and recommend vaccination against rubella postpartum", "B": "Recommend pregnancy termination", "C": "Arrange a chorionic villus sampling", "D": "Recommend additional serologic testing for parvovirus B19"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old gravida 1 presents", "physician", "weeks gestation", "prenatal appointment", "rash involving", "chest", "face", "arms", "watery nasal discharge", "mild bilateral knee pain", "symptoms", "5 days", "symptoms", "not", "to", "too much", "concerned", "baby", "contact with", "younger sister", "rash", "diagnosed", "rubella infection", "10 days", "family", "confirm", "vaccination history", "vital signs", "follows", "blood pressure", "70 mmHg", "heart rate", "min", "respiratory rate", "min", "temperature", "99", "Examination shows", "moderately dense maculopapular lacy rash spread", "patients trunk", "extremities", "face", "lymph node", "liver", "spleen enlargement", "noted", "knee joints appear normal", "Serology performed 1 year", "Current serology Rubella IgM", "negative", "1", "Rubella", "64 Rubella", "avidity", "high", "next step", "management", "woman"]}
{"question": "A 20-year-old woman presents with vaginal discharge, pruritus, and painful micturition for the past 5 days. She is sexually active with multiple partners and admits to using barrier protection inconsistently. Her last menstrual period was 2 weeks ago. The patient denies any fever, chills, abdominal pain, menorrhagia, or flank pain. She is afebrile and the vital signs are within normal limits. Speculum examination reveals vaginal erythema with a profuse, greenish-yellow, purulent, malodorous discharge. The vaginal pH is 5.5. Vaginal swab and urine samples are obtained for microscopy and culture, and results are pending. Which of the following is the most likely diagnosis in this patient based on her presentation?", "answer": "Trichomonal vaginitis", "options": {"A": "Urinary tract infection", "B": "Bacterial vaginosis", "C": "Trichomonal vaginitis", "D": "Chlamydia infection"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old woman presents", "vaginal discharge", "pruritus", "painful micturition", "past 5 days", "sexually active", "multiple partners", "admits", "using barrier protection", "last menstrual period", "2 weeks", "patient denies", "fever", "chills", "abdominal pain", "menorrhagia", "flank pain", "afebrile", "vital signs", "normal limits", "Speculum examination reveals vaginal erythema", "yellow", "purulent", "discharge", "vaginal pH", "5.5", "Vaginal swab", "urine samples", "obtained", "microscopy", "culture", "results", "following", "most likely diagnosis", "patient based", "presentation"]}
{"question": "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?", "answer": "6th pharyngeal arch", "options": {"A": "1st pharyngeal arch", "B": "2nd pharyngeal arch", "C": "3rd pharyngeal arch", "D": "6th pharyngeal arch"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old female", "thyroidectomy", "treatment", "Graves", "disease", "Post", "reports", "hoarse voice", "difficulty speaking", "suspect", "likely", "complication", "recent surgery", "embryologic origin", "damaged nerve", "most likely causing", "patient's hoarseness"]}
{"question": "A 15-year-old boy with poorly controlled asthma presents to the emergency room complaining of severe shortness of breath. His mother reports that he had trouble breathing soon after he started playing soccer with some friends and was unable to use his inhaler as it was empty. His family history is notable for emphysema in his paternal uncle and cirrhosis in his maternal grandfather. The child’s temperature is 99.0°F (37.2°C), blood pressure is 130/90 mmHg, pulse is 130/min, respirations are 28/min, and oxygen saturation is 91% on room air. Physical examination demonstrates wheezing bilaterally in all lung fields. The child is started on supplemental oxygen and a nebulized bronchodilator. Which of the following is a downstream effect of this medication?", "answer": "Increased adenylate cyclase activity", "options": {"A": "Decreased leukotriene activity", "B": "Activation of muscarinic receptors", "C": "Decreased phosphodiesterase activity", "D": "Increased adenylate cyclase activity"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "poorly controlled asthma presents", "emergency room", "of severe shortness", "breath", "mother reports", "trouble breathing", "started playing soccer", "friends", "unable to use", "inhaler", "empty", "family history", "notable", "emphysema", "paternal uncle", "cirrhosis", "maternal grandfather", "childs temperature", "99", "blood pressure", "90 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "Physical examination demonstrates wheezing", "lung fields", "child", "started", "supplemental oxygen", "nebulized bronchodilator", "following", "downstream effect", "medication"]}
{"question": "A 55-year-old man presents with a 2-month history of an increasing sensation of fullness in the upper left side of his abdomen. He complains of increasing fatigue and dyspnea. He has no history of serious illness and takes no medications. His temperature is 36.7°C (98.1°F), pulse is 90/min, respiratory rate is 18/min, and blood pressure is 125/70 mm Hg. His conjunctivae are pale. The examination of the heart and lungs shows no abnormalities. The splenic margin is palpable 8 cm (3.1 in) below the costal margin. No abnormal lymph nodes are found. Laboratory studies show:\nHemoglobin 8 g/dL\nMean corpuscular volume 90 μm3\nLeukocyte count 3,000/mm3\nPlatelet count 85,000/mm3\nPeripheral blood smear shows small lymphocytes with cell membrane projections. Bone marrow aspiration is unsuccessful. Cell immunophenotyping is positive for CD25. Which of the following is the most effective pharmacotherapy at this time?", "answer": "Cladribine", "options": {"A": "Cladribine", "B": "Fludarabine", "C": "Prednisone", "D": "Thalidomide"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man presents", "month history", "increasing sensation", "fullness", "upper left side of", "abdomen", "increasing fatigue", "dyspnea", "history", "serious illness", "takes", "medications", "temperature", "36", "98", "pulse", "90 min", "respiratory rate", "min", "blood pressure", "70 mm Hg", "conjunctivae", "pale", "examination of", "heart", "lungs shows", "abnormalities", "splenic margin", "palpable", "3.1", "costal margin", "abnormal lymph nodes", "found", "Laboratory studies show", "Hemoglobin", "g", "Mean corpuscular volume 90 m3 Leukocyte count", "mm3 Platelet", "Peripheral blood smear shows small lymphocytes", "cell membrane projections", "Bone marrow aspiration", "unsuccessful", "Cell immunophenotyping", "positive", "CD25", "following", "most effective pharmacotherapy", "time"]}
{"question": "A 57-year-old man presents to the emergency department with confusion. His symptoms started a few days ago and have been gradually worsening. Initially, the patient had a fever and a cough which has progressed to abdominal pain, diarrhea, and confusion. His temperature is 102°F (38.9°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 94% on room air. Physical exam is notable for localized crackles and decreased breath sounds in the left lower lung field. The patient is confused and is answering questions inappropriately. Laboratory studies are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 16,500/mm^3 with normal differential\nPlatelet count: 190,000/mm^3\n\nSerum:\nNa+: 130 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the best diagnostic test to guide current therapy in this patient?", "answer": "Urine antigen test", "options": {"A": "Chest radiography", "B": "Lung biopsy", "C": "Sputum culture", "D": "Urine antigen test"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["57 year old man presents", "emergency department", "confusion", "symptoms started", "few days", "worsening", "Initially", "patient", "fever", "cough", "progressed", "abdominal pain", "diarrhea", "confusion", "temperature", "blood pressure", "68 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "room air", "Physical exam", "notable", "localized crackles", "decreased breath sounds", "left lower lung field", "patient", "confused", "answering questions", "Laboratory studies", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "500 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL", "following", "best diagnostic test to guide current therapy", "patient"]}
{"question": "A 45-year-old man presents to the physician because of a 1-day history of progressive pain and blurry vision in his right eye. He is struggling to open this eye because of the pain. His left eye is asymptomatic. He wears contact lenses. He has bronchial asthma treated with inhaled salbutamol. He works as a kindergarten teacher. The vital signs include: temperature 37.0°C (98.6°F), pulse 85/min, and blood pressure 135/75 mm Hg. The examination shows a visual acuity in the left eye of 20/25 and the ability to count fingers at 3 feet in the right eye. A photograph of the right eye is shown. Which of the following is the most likely diagnosis?", "answer": "Pseudomonas keratitis", "options": {"A": "Angle-closure glaucoma", "B": "Epidemic keratoconjunctivitis", "C": "Herpes simplex keratitis", "D": "Pseudomonas keratitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "physician", "1-day history", "progressive pain", "blurry vision", "right eye", "to open", "eye", "pain", "left eye", "asymptomatic", "contact lenses", "bronchial asthma treated with inhaled salbutamol", "works", "kindergarten teacher", "vital signs include", "temperature", "98", "pulse 85 min", "blood pressure", "75 mm Hg", "examination shows", "visual acuity", "left eye", "20", "ability to count fingers", "3 feet", "right eye", "photograph", "right eye", "shown", "following", "most likely diagnosis"]}
{"question": "A 50-year-old man presents to his physician with chronic cough, aching joints in his hips and lower back, and malaise over the past 2 months. He describes himself as being “generally healthy” before the cough began. Past medical history includes hypertension. The patient takes clopamide and a multivitamin daily. His parents are both well and living in a senior living facility. He does not smoke and only drinks alcohol occasionally. During a review of symptoms, the patient described a hiking trip in and around the desert near Phoenix, Arizona, 4 months ago. At the office, his temperature is 38.6°C (101.4°F), heart rate is 102/min, respirations are 20/min, and blood pressure is 120/82 mm Hg. A focused chest exam reveals mild fremetus and dullness with percussion on the right side. A chest X-ray shows a right-sided consolidation of the lower right lung, and a chest CT shows an irregular opacity measuring 3.8 cm x 3.0 cm in the sub-plural region of the right middle lobe, a small right-sided pleural effusion, and mild right-sided hilar adenopathy. A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with multinucleated giant cells and spherules with endospores in the surrounding tissues. The laboratory tests show the following results:\nHemoglobin 12.9 mg/dL\nLeukocyte count 9,300/mm3\nPlatelet count 167,000/mm3\nErythrocyte sedimentation rate 43 mm/hr\nPeriodic acid-Schiff and silver methenamine Positive\nAcid-fast stain Negative\n Which of the following is the most likely diagnosis?", "answer": "Valley fever", "options": {"A": "Histoplasmosis", "B": "Mycetoma", "C": "Blastomycosis", "D": "Valley fever"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["50 year old man presents", "physician", "chronic cough", "aching joints", "hips", "lower back", "malaise", "past", "months", "healthy", "cough began", "Past medical history includes hypertension", "patient takes clopamide", "multivitamin daily", "parents", "well", "living", "senior", "facility", "not smoke", "only drinks alcohol occasionally", "review", "symptoms", "patient described", "hiking trip", "desert", "Phoenix", "Arizona", "4 months", "office", "temperature", "4F", "heart rate", "min", "respirations", "20 min", "blood pressure", "mm Hg", "focused chest exam reveals mild", "dullness", "percussion", "right side", "chest X-ray shows", "right-sided consolidation of", "lower", "lung", "chest CT shows", "irregular opacity measuring 3 8", "0", "sub plural region", "right middle lobe", "small right-sided pleural effusion", "mild right-sided hilar adenopathy", "lung biopsy", "performed to rule out cancer", "reveals necrotic granulomatous inflammation with multinucleated giant cells", "endospores", "surrounding tissues", "laboratory tests show", "following results", "Hemoglobin", "mg", "Leukocyte count", "mm3 Platelet", "Erythrocyte sedimentation rate", "hr Periodic acid-Schiff", "silver methenamine Positive Acid-fast Negative", "following", "most likely diagnosis"]}
{"question": "A 22-year-old man with sickle cell disease is brought to the emergency room for acute onset facial asymmetry and severe pain. He was in school when his teacher noted a drooping of his left face. His temperature is 99.9°F (37.7°C), blood pressure is 122/89 mmHg, pulse is 110/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam is notable for facial asymmetry and 4/5 strength in the patient's upper and lower extremity. A CT scan of the head does not demonstrate an intracranial bleed. Which of the following is the most appropriate treatment for this patient?", "answer": "Exchange transfusion", "options": {"A": "Alteplase", "B": "Exchange transfusion", "C": "Heparin", "D": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "sickle cell disease", "brought", "emergency room", "acute onset facial asymmetry", "severe pain", "in school", "teacher noted", "drooping", "left face", "temperature", "99 9F", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "facial asymmetry", "4/5 strength", "patient's upper", "lower extremity", "CT scan of", "head", "not", "intracranial bleed", "following", "most appropriate", "patient"]}
{"question": "A 3-month-old girl is brought to the physician because of a productive cough for 5 days. Over the past month, she has had several episodes of watery stools. She is exclusively breastfed every 3–4 hours for 15–20 minutes. She was delivered vaginally at 38 weeks' gestation at home and has not yet been evaluated by a physician. The mother reports that her child is not gaining weight. The mother had no prenatal care. The infant is at the 5th percentile for height and weight. The infant has not received any immunizations. Her temperature is 38.5°C (101.3°F), pulse is 155/min, respirations are 45/min, and blood pressure is 88/50 mm Hg. Oral examination shows white plaques covering the tongue and the palate. Rales are heard bilaterally on cardiopulmonary examination. Cervical and inguinal lymphadenopathy is present. Which of the following is most likely to confirm the diagnosis?", "answer": "Polymerase chain reaction for viral genes", "options": {"A": "Karyotyping of infant's chromosomes", "B": "DNA test for CFTR mutation", "C": "Fluorescent treponemal antibody absorption test", "D": "Polymerase chain reaction for viral genes"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 month old girl", "brought", "physician", "of", "productive cough", "5 days", "past month", "several episodes of watery stools", "breastfed", "hours", "minutes", "delivered", "weeks", "gestation at home", "not", "evaluated", "physician", "mother reports", "child", "not gaining weight", "mother", "prenatal care", "infant", "5th percentile", "height", "weight", "infant", "not received", "immunizations", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "88 50 mm Hg", "Oral examination shows white plaques covering", "tongue", "palate", "Rales", "heard", "cardiopulmonary examination", "Cervical", "inguinal lymphadenopathy", "present", "following", "most likely to confirm", "diagnosis"]}
{"question": "A 30-year-old primigravid woman at 22 weeks' gestation is brought to the emergency department by her husband for lethargy, nausea, and vomiting for 4 days. This morning she became drowsy. She returned from a business trip to Sudan 3 weeks ago. She denies eating any seafood while traveling. Medications include iron supplements and a multivitamin. Her immunizations are up-to-date and she has never received blood products. Her temperature is 38.9°C (102°F), pulse is 92/min, and blood pressure is 122/76 mm Hg. She is oriented to person and place. Examination shows jaundice and mild asterixis. Pelvic examination shows a uterus consistent in size with a 22-week gestation. Laboratory studies show:\nHemoglobin 11.2 g/dL\nProthrombin time 18 sec (INR=2.0)\nSerum\nTotal bilirubin 4.4 mg/dL\nAlkaline phosphatase 398 U/L\nAST 4,702 U/L\nALT 3,551 U/L\nLactate dehydrogenase 3,412 U/L\nAnti-nuclear antibody negative\nAnti-smooth muscle antibody negative\nAnti-CMV antibody negative\nAnti-EBV nuclear antigen antibody negative\nAn ELISA for HIV is negative. Which of the following is most likely to confirm the diagnosis?\"", "answer": "Anti-HEV IgM", "options": {"A": "HBsAg", "B": "Anti-HAV IgG", "C": "Anti-HCV IgG", "D": "Anti-HEV IgM"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["30 year old primigravid woman", "weeks", "estation ", "rought ", "mergency department ", "usband ", "ethargy,", "ausea,", "omiting ", " days.", "orning ", "rowsy.", "eturned ", "usiness  rip ", "udan ", "eeks ", "enies  ating ", "eafood ", "raveling.", "edications  nclude  ron supplements ", "ultivitamin.", "mmunizations ", "ate ", "ever  eceived  lood products.", "emperature ", "ulse ", "in,", "lood pressure ", "6  m Hg.", "riented to person ", "lace.", "xamination  hows  aundice ", "ild  sterixis.", "elvic examination  hows ", "terus  onsistent ", "ize ", "eek gestation.", "aboratory studies  how:", "emoglobin ", "/ rothrombin time ", "ec ", "NR= . )", "erum ", "g/dL ", " ", "actate dehydrogenase ", "nti-", "mooth muscle antibody ", "BV ", "ntigen  ntibody negative ", "LISA ", "IV ", "egative.", "ollowing ", "ost likely  o  onfirm ", "iagnosis?"]}
{"question": "A 36-year-old man is brought to the emergency department because of multiple episodes of nonbilious emesis for 3 days. The vomitus consists of undigested food and he has also had dark brown emesis twice today. He has been having early satiety during this period. He has had progressive severe episodic epigastric pain and dyspepsia for the past week. The pain is partially relieved with food or over-the-counter antacids, but worsens at night and several hours after eating. He has also had a weight gain of 2 kg (4.4 lbs) during this period. His father underwent surgery for colon cancer 3 years ago. He has smoked one pack of cigarettes daily for the last 15 years. He drinks two to three beers daily. His temperature is 37.1°C (98.8°F), pulse is 106/min and blood pressure is 108/68 mm Hg. Examination shows dry mucous membranes. The abdomen is mildly tender to palpation in the left upper quadrant; there is a tympanitic mass in the epigastrium. A succussion splash is heard with a stethoscope when the patient is rocked back and forth at the hips. Bowel sounds are reduced. Rectal examination is unremarkable. Test of the stool for occult blood is positive. The remainder of the examination shows no abnormalities. Serum studies show:\nNa+ 135 mEq/L\nK+ 3.3 mEq/L\nCl- 97 mEq/L\nUrea nitrogen 46 mg/dL\nGlucose 77 mg/dL\nCreatinine 1.4 mg/dL\nWhich of the following is the underlying cause of this patient's vomiting?\"", "answer": "Inflammation and edema", "options": {"A": "Inflammation and edema", "B": "Abnormal gastric rotation", "C": "Neoplastic growth", "D": "Walled-off pancreatic fluid collection"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old man", "brought", "emergency department", "of multiple episodes", "nonbilious emesis", "3 days", "vomitus consists", "undigested food", "dark brown emesis twice today", "early satiety", "period", "progressive severe episodic epigastric", "dyspepsia", "past week", "pain", "relieved with food", "over-the-counter antacids", "worsens", "night", "several hours", "eating", "weight gain", "kg", "4.4 lbs", "period", "father", "surgery", "colon cancer 3 years", "smoked one pack", "cigarettes daily", "last", "years", "drinks two", "three beers daily", "temperature", "98", "pulse", "min", "blood pressure", "68 mm Hg", "Examination shows dry mucous membranes", "abdomen", "mildly tender", "palpation", "left upper quadrant", "tympanitic mass", "epigastrium", "splash", "heard", "stethoscope", "patient", "back", "hips", "Bowel sounds", "reduced", "Rectal examination", "unremarkable", "Test", "stool", "occult blood", "positive", "examination shows", "abnormalities", "Serum studies show", "Na", "mEq", "97", "Urea nitrogen", "mg", "Glucose", "Creatinine 1", "following", "underlying cause", "patient", "omiting?"]}
{"question": "A 52-year-old man is brought to the emergency department because of worsening shortness of breath for 6 hours. For the past 5 days, he has had intermittent stabbing pain in the middle of his chest that worsens with lying down or taking deep breaths. He has also had a runny nose and a dry cough for the past 2 weeks. He has hypercholesterolemia and hypertension. He has smoked a pack of cigarettes daily for 34 years. His current medications include atorvastatin, enalapril, and hydrochlorothiazide. He appears pale and sweaty. His temperature is 38.3°C (100.9°F), pulse is 105/min, and respirations are 25/min. Blood pressure is 107/72 mm Hg during expiration and 86/65 mm Hg during inspiration. Examination shows jugular venous distention and pitting edema below the knees. Which of the following is the most likely cause of this patient's findings?", "answer": "Accumulation of fluid in the pericardial space", "options": {"A": "Dilation of the atria and ventricles", "B": "Occlusion of a coronary artery", "C": "Accumulation of fluid in the pericardial space", "D": "Fibrous thickening of the pericardium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "of worsening shortness", "breath", "6 hours", "past", "days", "intermittent stabbing pain in the middle", "chest", "worsens", "lying", "taking deep breaths", "runny nose", "dry cough", "past 2 weeks", "hypercholesterolemia", "hypertension", "smoked", "pack", "cigarettes daily", "years", "current medications include atorvastatin", "enalapril", "hydrochlorothiazide", "appears pale", "sweaty", "temperature", "3C", "100 9F", "pulse", "min", "respirations", "min", "Blood pressure", "72 mm Hg", "expiration", "65 mm Hg", "inspiration", "Examination shows jugular venous distention", "pitting", "knees", "following", "most likely cause", "patient's findings"]}
{"question": "A 70-year-old obese male presents to the emergency department with shortness of breath and cough of sudden onset. The patient states that his symptoms came on while he was sleeping. The patient has a past medical history of type II diabetes and is currently taking lisinopril, metformin, insulin, and fish oil. On physical exam, you note bipedal edema and jugular venous distention (JVD). An EKG and chest radiographs are obtained (Figures A and B). The patient is started on BIPAP and medical therapy and his symptoms improve rapidly. Lab values are as follows.\n\nSerum:\nNa+: 137 mEq/L\nK+: 3.2 mEq/L\nCl-: 100 mEq/L\nHCO3-: 31 mEq/L\nBUN: 20 mg/dL\nGlucose: 120 mg/dL\nCreatinine: 1.2 mg/dL\nCa2+: 10.9 mg/dL\n\nWhich of the following is the best explanation of this patient's current presentation?", "answer": "Hydrochlorothiazide", "options": {"A": "Furosemide", "B": "Hydrochlorothiazide", "C": "Renal tubular acidosis type II", "D": "Renal tubular acidosis type IV"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["70 year old obese male presents", "emergency department", "shortness of breath", "cough", "sudden onset", "patient states", "symptoms", "sleeping", "patient", "a past medical type II diabetes", "currently taking lisinopril", "metformin", "insulin", "fish oil", "physical exam", "note", "edema", "jugular venous distention", "EKG", "chest radiographs", "obtained", "patient", "started", "BIPAP", "medical therapy", "symptoms", "rapidly", "Lab values", "follows", "Serum", "Na", "137 mEq L K", "3.2 mEq/L Cl", "100 mEq/L HCO3", "31 mEq/L", "20 mg/dL Glucose", "mg/dL Creatinine", "1.2 mg/dL Ca2", "10 9 mg dL", "following", "best explanation", "patient's current presentation"]}
{"question": "A 23-year-old woman is seen by her primary care physician for fatigue. She says that she has always felt a little short of breath compared to her friends; however, she did not think that it was abnormal until she started trying a new exercise regimen. On physical exam, she is found to have mild conjunctival pallor and a peripheral blood smear is obtained showing echinocytes but no intracellular accumulations. Upon further questioning, she recalls that several relatives have had similar issues with fatigue and pallor in the past. Which of the following is true about the rate limiting enzyme of the biochemical pathway that is affected by this patient's most likely condition?", "answer": "It is inhibited by protein kinase A activity", "options": {"A": "It is stimulated by ATP", "B": "It is stimulated by citrate", "C": "It is inhibited by protein kinase A activity", "D": "It is inhibited by AMP"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old woman", "seen by", "primary care physician", "fatigue", "always felt", "little short of breath compared", "friends", "not think", "abnormal", "started", "new exercise regimen", "physical exam", "found to", "mild conjunctival pallor", "peripheral blood smear", "obtained showing echinocytes", "intracellular accumulations", "further questioning", "recalls", "several relatives", "similar issues", "fatigue", "pallor", "past", "following", "true", "rate limiting enzyme", "biochemical", "affected", "patient's", "likely condition"]}
{"question": "A 32-year-old woman comes to the physician because she feels depressed, has difficulty sleeping, a poor appetite, and low concentration for the past 3 months. During this time, she has also had low energy and lost interest in playing the guitar. During high school, the patient went through similar episodes of low mood and poor sleep. At that time, she would repeatedly engage in binge eating and purging behavior, for which she was referred to therapy. There is no evidence of suicidal ideation. The physician offers to prescribe a medication for her current symptoms. Treatment with which of the following drugs should most be avoided in this patient?", "answer": "Bupropion", "options": {"A": "Duloxetine", "B": "Trazodone", "C": "Bupropion", "D": "Citalopram"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "feels depressed", "difficulty sleeping", "poor appetite", "low concentration", "past 3 months", "time", "low energy", "lost interest", "playing", "high school", "patient", "similar episodes of low mood", "poor sleep", "time", "repeatedly", "binge eating", "purging behavior", "referred", "therapy", "evidence", "suicidal ideation", "physician", "to", "medication", "current symptoms", "Treatment", "following drugs", "most", "patient"]}
{"question": "A 5-month-old boy is brought to the physician with a 3-day history of fever and cough. His mother reports that he has had multiple episodes of loose stools over the past 3 months. He has been treated for otitis media 4 times and bronchiolitis 3 times since birth. He was born at 37 weeks' gestation, and the neonatal period was uncomplicated. He is at the 10th percentile for height and 3rd percentile for weight. His temperature is 38.3°C (100.9°F), pulse is 126/min, and respirations are 35/min. Examination shows an erythematous scaly rash over his trunk and extremities. The white patches on the tongue and buccal mucosa bleed when scraped. Inspiratory crackles are heard in the right lung base. An X-ray of the chest shows an infiltrate in the right lower lobe and an absent thymic shadow. Which of the following is the most likely definitive treatment for this patient’s condition?", "answer": "Hematopoietic cell transplantation", "options": {"A": "Hematopoietic cell transplantation", "B": "Intravenous immune globulin", "C": "Leucovorin supplementation", "D": "Thymic transplantation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["5 month old boy", "brought", "physician", "3-day history", "fever", "cough", "mother reports", "multiple episodes of loose stools", "past 3 months", "treated", "otitis media", "times", "bronchiolitis", "times", "birth", "born", "weeks", "gestation", "neonatal period", "uncomplicated", "percentile", "height", "3rd percentile", "weight", "temperature", "3C", "100 9F", "pulse", "min", "respirations", "35 min", "Examination shows", "erythematous scaly rash", "trunk", "extremities", "white patches", "tongue", "buccal mucosa bleed", "scraped", "Inspiratory crackles", "heard", "right lung base", "X-ray of", "chest shows", "infiltrate", "right lower lobe", "absent thymic shadow", "following", "most likely definitive treatment", "patients condition"]}
{"question": "Six days after undergoing an aortic valve replacement surgery, a 68-year-old woman has bluish discolorations around the peripheral intravenous catheters and severe right leg pain. She has a history of hypertension and major depressive disorder. She drinks 3 beers daily. Current medications include hydrochlorothiazide, aspirin, prophylactic unfractionated heparin, and fluoxetine. Her temperature is 37.3°C (99.1°F), pulse is 90/min, and blood pressure is 118/92 mm Hg. Examination shows multiple hematomas on the upper extremities around the peripheral intravenous access sites. There is a healing sternal incision. The lungs are clear to auscultation. Cardiac examination shows an aortic click. The right calf is tender, erythematous and swollen. Laboratory studies show:\nHemoglobin 13.1 g/dL\nLeukocyte count 9,900/mm3\nPlatelet count 48,000/mm3\nProthrombin time 15 seconds\nActivated partial thromboplastin time 40 seconds\nSerum\nUrea nitrogen 19 mg/dL\nCreatinine 1.1 mg/dL\nAlkaline phosphatase 33 U/L\nAST 26 U/L\nALT 33 U/L\nγ-Glutamyl transferase 45 U/L (N=5–50 U/L)\nWhich of the following is the most likely underlying mechanism of this patient's symptoms?\"", "answer": "Autoantibody-mediated platelet activation", "options": {"A": "Deficiency of vitamin K-dependent clotting factors", "B": "Phagocytosis of autoantibody-opsonized platelets", "C": "Excess circulating thrombin", "D": "Autoantibody-mediated platelet activation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Six days", "aortic valve replacement surgery", "68 year old woman", "discolorations", "peripheral intravenous catheters", "severe right leg pain", "history of hypertension", "major depressive disorder", "drinks 3 beers daily", "Current medications include hydrochlorothiazide", "aspirin", "prophylactic unfractionated heparin", "fluoxetine", "temperature", "3C", "99", "pulse", "90 min", "blood pressure", "mm Hg", "Examination shows multiple hematomas", "upper extremities", "peripheral intravenous access sites", "healing sternal incision", "lungs", "clear", "auscultation", "Cardiac examination shows", "aortic", "right calf", "tender", "erythematous", "swollen", "Laboratory studies show", "Hemoglobin", "Leukocyte", "mm3 Platelet count", "Prothrombin time", "Activated partial thromboplastin time", "Serum Urea nitrogen", "Creatinine", "Alkaline phosphatase", "L", "Glutamyl transferase", "N 550 U/L", "following", "most likely underlying mechanism", "patient", "ymptoms?"]}
{"question": "A 55-year-old man with chronic hepatitis B virus infection comes to the physician because of generalized fatigue and a 5.4 kg (12 lb) weight loss over the past 4 months. Physical examination shows hepatomegaly. Laboratory studies show an α-fetoprotein concentration of 380 ng/ml (N < 10 ng/mL). A CT scan of the abdomen with contrast shows a solitary mass in the left lobe of the liver that enhances in the arterial phase. Which of the following is the most likely underlying pathogenesis of this patient's current condition?", "answer": "Integration of foreign DNA into host genome\n\"", "options": {"A": "Overexpression of secretory hepatitis antigen", "B": "Intracellular accumulation of misfolded protein", "C": "Gain of function mutation of a proto-oncogene", "D": "Integration of foreign DNA into host genome\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["55 year old man", "chronic hepatitis B virus infection", "physician", "generalized fatigue", "5.4 kg", "weight loss", "past", "months", "Physical examination shows hepatomegaly", "Laboratory studies show", "fetoprotein concentration", "ng/ml", "N", "10 ng/mL", "CT scan", "abdomen", "contrast shows", "solitary mass", "the left lobe of", "liver", "enhances", "arterial phase", "following", "most likely underlying pathogenesis", "patient's current condition"]}
{"question": "A 28-year-old woman with no significant past medical history presents to her primary care physician with increased menstrual bleeding over the past three months. She also notes easy bruising and bleeding from her gums when brushing her teeth. She is sexually active with multiple partners and has no history of intravenous drug use. Physical exam is remarkable for petechiae and scattered ecchymoses on the patient's bilateral upper and lower extremities. Urine beta-HCG is negative. Laboratory results are as follows: Hgb 13.0 g/dL, WBCs 6,000/mL, platelets 95,000/mL, PT 13.2s, aPTT 30s. Peripheral blood smear shows normocytic, normochromic red blood cells and few platelets with no morphologic abnormalities. Which diagnostic study should be performed next?", "answer": "HIV and HCV testing", "options": {"A": "Serum factor VIII levels and von Willebrand factor activity", "B": "Measurement of ADAMTS13 activity", "C": "HIV and HCV testing", "D": "Bone marrow aspiration"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "significant past medical history presents", "primary care physician", "increased menstrual bleeding", "past three months", "notes easy bruising", "bleeding", "gums", "brushing", "teeth", "sexually active", "multiple partners", "history", "intravenous drug use", "Physical exam", "petechiae", "scattered ecchymoses", "patient's bilateral upper", "lower extremities", "Urine beta-HCG", "negative", "Laboratory", "follows", "Hgb", "0 g/dL", "WBCs", "mL", "platelets 95", "mL", "PT", "2s", "aPTT 30s", "Peripheral blood smear shows normocytic", "normochromic red blood cells", "few platelets", "morphologic abnormalities", "diagnostic study", "performed next"]}
{"question": "A 6-year-old boy is brought in by his parents to a pediatrician’s office for persistent fever. His temperature has ranged from 38.6°C–39.5°C (101.5°F–103.1°F) over the past week. He was diagnosed with a gene defect on chromosome 7, which has caused dysfunction in a transmembrane protein. This defect has resulted in several hospitalizations for various respiratory infections. At the present time, he is struggling with a cough with thick purulent sputum. A sputum sample is sent for culture and the patient is started on vancomycin.The pediatrician tells the patient’s family that there is a collection of mucus in the respiratory tree which increases the patient's chances of future infections. He will have to undergo chest physiotherapy and they should report any signs of infection immediately to a medical professional. Which of the following pathogens will most likely infect this patient in adulthood?", "answer": "Pseudomonas", "options": {"A": "Staphylococcus", "B": "Pseudomonas", "C": "Burkholderia", "D": "Candida"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "parents", "pediatricians office", "persistent fever", "temperature", "ranged", "past week", "diagnosed", "gene defect", "chromosome 7", "caused dysfunction", "a transmembrane protein", "defect", "resulted", "hospitalizations", "various respiratory infections", "present time", "cough", "thick purulent", "sputum sample", "sent", "culture", "patient", "started", "vancomycin", "pediatrician", "patients family", "collection", "mucus", "respiratory tree", "increases", "patient's chances", "future infections", "to", "chest physiotherapy", "report", "signs", "infection immediately", "medical professional", "following pathogens", "most likely infect", "patient", "adulthood"]}
{"question": "An 8-week-old male presents with his mother to the pediatrician for a well visit. The patient has been breastfed since birth, and usually feeds for 30 minutes every 2-3 hours. The patient’s mother is concerned that her milk production is not keeping up with the patient’s nutritional requirements. She reports that about two weeks ago the patient began regurgitating breastmilk through his nose and mouth after some feeds. She reports that he seems mildly upset during the episodes of regurgitation but usually settles down quickly and is hungry again soon afterwards. The patient’s mother has already tried limiting the volume of each feed, which seems to have reduced the frequency of the regurgitation. She denies any diarrhea, hematochezia, or family history of food allergies. Her older son had a similar problem with vomiting that resolved around 12 months of age. Four weeks ago, the patient’s height and weight were in the 40th and 34th percentiles, respectively. His height and weight are now respectively in the 37th and 36th percentiles. On physical exam, the patient is cooing in his mother’s lap and smiles reciprocally with her. He lifts his head and shoulders off the examination table when placed in the supine position. His abdomen is soft, non-tender and non-distended. Bowel sounds are normoactive.\n\nWhich of the following is the best next step in management?", "answer": "Reassurance and counseling on positioning", "options": {"A": "Initiate proton pump inhibitor", "B": "Obtain abdominal ultrasound", "C": "Reassurance and counseling on positioning", "D": "Recommend modification of mother’s diet"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["week old male presents", "mother", "pediatrician", "well visit", "patient", "breastfed", "birth", "usually feeds", "30 minutes", "2", "hours", "patients mother", "concerned", "milk production", "not keeping", "patients nutritional requirements", "reports", "two weeks", "patient began regurgitating breastmilk", "nose", "mouth", "feeds", "reports", "mildly upset", "episodes of regurgitation", "usually settles", "hungry", "patients mother", "limiting", "volume", "feed", "to", "reduced", "frequency", "regurgitation", "denies", "diarrhea", "hematochezia", "family allergies", "older son", "similar problem", "vomiting", "resolved", "12 months", "age", "Four weeks", "patients height", "weight", "percentiles", "height", "weight", "now", "percentiles", "physical exam", "patient", "cooing", "mothers lap", "smiles", "lifts", "head", "shoulders", "examination table", "placed", "supine position", "abdomen", "soft", "non-tender", "non distended", "Bowel sounds", "following", "best next step", "management"]}
{"question": "A 27-year-old gentleman is brought into the ED after being stabbed in the back by a knife. In addition to the pain from the wound, he complains of weakness in his left leg. Upon physical examination you find that he has no other visible injuries; however, he has 2/5 strength in the left lower extremity. Complete neurologic exam also finds a deficit in vibration sense and light touch on the left lower extremity as well as a loss of pain and temperature sensation in the right lower extremity. Which of the following lesions would result in the syndrome described?", "answer": "Left cord hemisection", "options": {"A": "Anterior cord lesion", "B": "Posterior cord lesion", "C": "Right cord hemisection", "D": "Left cord hemisection"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old", "brought", "ED", "stabbed", "back", "knife", "In addition to", "pain", "wound", "weakness", "left leg", "physical examination", "find", "visible injuries", "has", "strength", "left lower extremity", "Complete neurologic exam", "finds", "deficit", "vibration sense", "light touch", "left lower extremity", "loss", "pain", "temperature sensation", "right lower extremity", "following lesions", "result", "syndrome described"]}
{"question": "A 58-year-old African American man presents for his yearly wellness visit. He says he has been unsuccessful at losing weight and would like help. His last colonoscopy was 8 years previously, which was normal. Past medical history is significant for obstructive sleep apnea (OSA) and hypertension. Current medications are isosorbide dinitrate/hydralazine and aspirin 81 mg orally daily. He is also on CPAP to manage his OSA. The patient denies any history of smoking or recreational drug use and drinks 1 or 2 beers on weekends. Family history is significant for prostate cancer in his father and hypertension and diabetes mellitus type 2 in his mother. His vital signs include: temperature 36.8°C (98.2°F), pulse 97/min, respiratory rate 16/min, blood pressure 120/75 mm Hg. BMI is 30 kg/m2. Physical examination is unremarkable. Fasting blood glucose is 90 mg/dL. Which of the following preventative screening tests would be most appropriate for this patient at this time?", "answer": "PSA", "options": {"A": "PSA", "B": "Digital rectal exam", "C": "Abdominal ultrasound", "D": "Flexible sigmoidoscopy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old African American man presents", "yearly wellness visit", "unsuccessful", "weight", "help", "last colonoscopy", "years", "normal", "Past medical history", "significant", "obstructive sleep apnea", "hypertension", "Current medications", "isosorbide dinitrate/hydralazine", "aspirin 81 mg orally daily", "CPAP to", "OSA", "patient denies", "history of smoking", "recreational drug use", "drinks 1", "2 beers", "weekends", "Family history", "significant", "prostate cancer", "father", "hypertension", "diabetes", "type 2", "mother", "vital signs include", "temperature 36", "98", "pulse 97 min", "respiratory rate", "min", "blood pressure", "75 mm Hg", "BMI", "30 kg/m2", "Physical examination", "unremarkable", "Fasting blood glucose", "90 mg/dL", "following preventative screening tests", "most appropriate", "patient", "time"]}
{"question": "A 34-year-old patient is brought to the emergency room after a motor vehicle accident. An EKG shows sinus tachycardia and chest radiograph reveals an enlarged cardiac silhouette. While observing sinus tachycardia on the patient's telemetry, you note that the radial pulse cannot be palpated during inspiration. What should be the next step in management of this patient?", "answer": "Pericardiocentesis", "options": {"A": "Pericardiocentesis", "B": "Chest CT scan", "C": "Pericardial window", "D": "Insert chest tube"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old patient", "brought", "emergency room", "motor vehicle accident", "EKG shows sinus tachycardia", "chest radiograph reveals", "enlarged cardiac silhouette", "observing sinus tachycardia", "patient's telemetry", "note", "radial pulse", "palpated", "inspiration", "next step", "management", "patient"]}
{"question": "A previously healthy 60-year-old man comes to his physician because of progressively worsening shortness of breath for the past 2 months. He does not experience shortness of breath at rest. He also occasionally has a dry cough. He has not had fever, chills, or night sweats. He has smoked a pack of cigarettes daily for the past 40 years. He drinks a beer daily and occasionally more on weekends. He does not use illicit drugs. He is 183 cm (6 ft 0 in) tall and weighs 66 kg (145 lbs); BMI is 19.7 kg/m2. His temperature is 37°C (98.6°F), pulse is 94/min, respirations are 21/min, and blood pressure is 136/88 mm Hg. Lung auscultation reveals a prolonged expiratory phase and end-expiratory wheezing. Spirometry shows an FEV1:FVC ratio of 62%, an FEV1 of 60% of predicted, and a total lung capacity of 125% of predicted. The diffusion capacity of the lung (DLCO) is decreased. Which of the following is the most likely diagnosis?", "answer": "Chronic obstructive pulmonary disease", "options": {"A": "Interstitial lung disease", "B": "Hypersensitivity pneumonitis", "C": "Chronic obstructive pulmonary disease", "D": "Bronchiectasis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy 60 year old man", "physician", "worsening shortness of breath", "past", "months", "not experience shortness of breath", "rest", "occasionally", "dry cough", "not", "fever", "chills", "night sweats", "smoked", "pack", "cigarettes daily", "past 40 years", "drinks", "beer daily", "occasionally", "weekends", "not use illicit drugs", "6 ft 0", "tall", "66 kg", "lbs", "BMI", "kg/m2", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "88 mm Hg", "Lung auscultation reveals", "prolonged expiratory phase", "end", "Spirometry shows", "FEV1:FVC ratio", "62", "FEV1", "60", "predicted", "total lung capacity", "predicted", "diffusion capacity of", "lung", "decreased", "following", "most likely diagnosis"]}
{"question": "A 29-year-old G1P0 woman is giving birth at 38 weeks gestation to a  boy via vaginal delivery. As soon as the infant is clear of the vagina, a congenital malformation of the abdomen is observed. The infant is removed from the delivery room for further evaluation. Visual inspection shows loops of intestine protruding out of his abdomen on the right side. His APGAR scores are 7 at 1 minute and 9 at 5 minutes. His heart rate is 125/min, and his respirations are 45/min. All reflexes appear normal. There are no other visible defects. Which of the following is the most appropriate next step in management?", "answer": "Wrap the intestines in a sterile bowel bag", "options": {"A": "Wrap the intestines in a sterile bowel bag", "B": "Transfer the newborn to the NICU", "C": "Start IV fluids", "D": "Transfer the newborn for immediate surgery"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old", "woman", "giving birth", "weeks gestation", "boy", "vaginal delivery", "infant", "clear", "vagina", "congenital malformation", "abdomen", "observed", "infant", "removed", "delivery room", "further evaluation", "Visual inspection shows loops", "intestine protruding out of", "abdomen", "right side", "APGAR scores", "minute", "5 minutes", "heart rate", "min", "respirations", "min", "reflexes appear normal", "visible defects", "following", "most appropriate next step", "management"]}
{"question": "A 54-year-old woman presents with fatigue, malaise, and shortness of breath over the past 5 months. Past medical history is significant for rheumatoid arthritis diagnosed 23 years ago for which she takes naproxen as needed. Her vital signs include: temperature 36.9°C (98.4°F), blood pressure 135/88 mm Hg, pulse 92/min. Physical examination is significant for conjunctival pallor and bilateral ulnar deviation of the metacarpophalangeal joints. Laboratory findings are significant for the following:\nHemoglobin 9.2 g/dL\nMean corpuscular volume 76 fL\nLeukocyte count 7,000/mm3\nPlatelet count 220,000/mm3\nSerum ferritin 310 ng/mL\nErythrocyte sedimentation rate 85 mm/h\nWhich of the following is a feature of this patient's anemia?", "answer": "Upregulation of hepcidin", "options": {"A": "↑ serum transferrin receptors", "B": "↑ transferrin saturation", "C": "Upregulation of hepcidin", "D": "↑ reticulocyte count"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["54 year old woman presents", "fatigue", "malaise", "shortness of breath", "past", "months", "medical history", "significant", "rheumatoid arthritis diagnosed 23 years", "takes naproxen as needed", "vital signs include", "temperature 36", "98 4F", "blood pressure", "88 mm Hg", "pulse", "min", "Physical examination", "significant", "conjunctival pallor", "bilateral ulnar deviation of the metacarpophalangeal joints", "Laboratory findings", "significant", "following", "Hemoglobin", "g/dL Mean corpuscular volume 76 fL Leukocyte count 7", "mm3 Platelet count", "Serum ferritin", "Erythrocyte sedimentation rate", "h", "following", "feature", "patient's anemia"]}
{"question": "A six-year-old boy with a history of asthma currently uses an albuterol inhaler as needed to manage his asthma symptoms. His mother brings him into your office because she feels she has had to increase the patient’s use of his inhaler to four times per week for the past month. She also reports that he has woken up three times during the night from his symptoms this month. The boy reports that he is upset because he can’t always keep up with his friends in the playground. His past medical history is significant for allergic rhinitis. The patient’s temperature is 98°F (36.6°C), blood pressure is 110/70 mmHg, pulse is 88/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air. Auscultation of his lungs reveals bilateral late expiratory wheezes.\n\nWhat changes should be made to his current asthma treatment regimen?", "answer": "Add fluticasone daily", "options": {"A": "Maintain current therapy", "B": "Add fluticasone daily", "C": "Add salmeterol twice daily", "D": "Add zileuton twice daily"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["six year old boy", "history of asthma currently uses", "albuterol inhaler as needed to", "asthma symptoms", "mother", "office", "feels", "to increase", "patients use of", "inhaler", "four times", "week", "past month", "reports", "woken up three times", "night", "symptoms", "month", "boy reports", "upset", "cant always keep", "friends", "playground", "past medical history", "significant", "allergic rhinitis", "patients temperature", "36", "blood pressure", "70 mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "98", "O2", "room air", "Auscultation", "lungs reveals bilateral late expiratory wheezes", "changes", "made", "current asthma treatment"]}
{"question": "A 25-year-old woman comes to the office complaining of pelvic pain and feeling “off” for the past few weeks. She has not had any changes in diet or lifestyle but reports weight loss despite an increase in appetite. In addition, she has been experiencing chest palpitations, increased frequency of diarrhea, and heat intolerance. Physical exam of her thyroid is unremarkable but her TSH was found to be 0.21 mIU/L. A complex structure in her right ovary was detected on ultrasound. Her symptoms can be explained by which of the following?", "answer": "Struma ovarii", "options": {"A": "Meigs syndrome", "B": "Jod-Basedow phenomenon", "C": "Dermoid cyst", "D": "Struma ovarii"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "office complaining of pelvic pain", "feeling", "past", "weeks", "not", "changes in diet", "lifestyle", "reports weight loss", "increase", "appetite", "addition", "experiencing chest palpitations", "increased frequency of diarrhea", "heat intolerance", "Physical exam of", "thyroid", "unremarkable", "found to", "0.21 mIU/L", "complex structure", "right ovary", "detected", "ultrasound", "symptoms"]}
{"question": "An otherwise healthy 15-year-old boy presents to the emergency department with extreme fatigue and shortness of breath. His temperature is 36.5°C (97.7°F), the blood pressure is 100/60 mm Hg and the pulse is 100/min. Past medical history is noncontributory and he takes no medication. His father and aunt both suffer from mild anemia. On examination, he is very pale and his spleen is enlarged. His hemoglobin is 5 g/dL and platelet count is slightly reduced. His peripheral blood smear is shown in the picture. Over the next 2 weeks, the patient recovers, and his hemoglobin is 11 g/dL. Which of the following best represents the pattern of inheritance of this patient underlying disorder?", "answer": "Autosomal dominant", "options": {"A": "Autosomal dominant", "B": "X-linked recessive", "C": "X-linked dominant", "D": "Multifactorial"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy presents", "emergency department", "extreme fatigue", "shortness of breath", "temperature", "36", "97", "blood pressure", "100 60 mm Hg", "pulse", "100 min", "Past medical history", "takes", "medication", "father", "aunt", "suffer", "mild anemia", "examination", "very pale", "spleen", "enlarged", "hemoglobin", "5 g/dL", "platelet count", "slightly reduced", "peripheral blood smear", "shown", "picture", "next", "weeks", "patient recovers", "hemoglobin", "g/dL", "following best represents", "pattern", "inheritance", "patient underlying disorder"]}
{"question": "A 65-year-old male presents to the emergency department from his home complaining of dyspnea. He is alert and oriented. The following arterial blood gas readings are drawn: pH: 7.33 (Normal: 7.35-7.45), pCO2: 70 mmHg (Normal: 35-45 mmHg), HCO3 33 (Normal: 21-26 mEq/L) Which of the following is most likely to have produced this patient’s condition?", "answer": "Chronic obstructive bronchitis", "options": {"A": "Panic attack", "B": "Mechanical ventilation", "C": "Pulmonary embolus", "D": "Chronic obstructive bronchitis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65 year old male presents", "emergency department", "home", "dyspnea", "alert", "oriented", "following arterial blood gas readings", "drawn", "pH", "Normal", "7 35 7", "pCO2", "70 mmHg", "Normal", "35", "mmHg", "HCO3", "Normal", "mEq/L", "following", "most likely to", "patients condition"]}
{"question": "A 23-year-old man is admitted to the hospital with fever, chest discomfort, tachypnea, pain, needle-like sensations in the upper extremities, and profuse sweating. He also complains of a gradual decrease in vision over the past 3 months. He is a bodybuilding competitor and has a competition coming up in 1 week. The man reports that his symptoms appeared suddenly, 30 minutes after he took 2 foreign-manufactured fat-burning pills instead of the 1 he usually takes. His blood pressure is 140/90 mm Hg, heart rate is 137/min, respiratory rate is 26/min, and temperature is 39.9°C (103.8°F). Physical examination reveals a reddish maculopapular rash over the patient’s trunk, diminished lung and heart sounds, tenderness to palpation in his abdomen, and rotational bilateral nystagmus with an alternating gaze-dependent fast component. Ophthalmologic examination shows bilateral cataracts. The patient’s total blood count is as follows:\nErythrocytes 4.4 x 109/mm3\nHb 12 g/dL\nTotal leukocyte count  3750/mm3\nNeutrophils 57%\nLymphocyte 37%\nEosinophil 1%\nMonocyte 5%\nBasophil 0%\nPlatelet count 209,000/mm3\nWhich of the following statements best describes the pathogenesis of this patient’s condition?", "answer": "The drug caused uncoupling of the electron transport chain and oxidative phosphorylation.", "options": {"A": "The patient’s symptoms are caused by an increased concentration of epinephrine released by the adrenal glands in response to the consumed substance.", "B": "The drug caused uncoupling of the electron transport chain and oxidative phosphorylation.", "C": "The patient has a pyretic reaction due to bacterial contamination of the pills.", "D": "The drug has stimulated the hypothalamic temperature center to produce hyperthermia."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old man", "admitted", "hospital", "fever", "chest discomfort", "tachypnea", "pain", "needle", "sensations", "upper extremities", "profuse sweating", "gradual decrease", "vision", "past 3 months", "bodybuilding", "competition", "1 week", "man reports", "symptoms appeared", "30 minutes", "took 2 foreign manufactured fat-burning pills", "1", "usually takes", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "Physical examination reveals", "maculopapular rash", "patients trunk", "diminished lung", "heart sounds", "tenderness", "palpation", "abdomen", "rotational bilateral nystagmus", "alternating gaze dependent fast component", "Ophthalmologic examination shows bilateral cataracts", "patients total blood count", "follows", "Erythrocytes", "mm3 Hb 12 g/dL Total leukocyte count", "3750", "57", "Lymphocyte", "Eosinophil", "Monocyte 5", "Basophil 0", "Platelet count", "following statements best", "pathogenesis", "patients condition"]}
{"question": "A 23-year-old woman comes to the physician because of progressive fatigue and painful swelling of her right knee for 3 weeks. She works as a professional ballet dancer and says, “I'm always trying to be in shape for my upcoming performances.” She is 163 cm (5 ft 4 in) tall and weighs 45 kg (99 lb); BMI is 17 kg/m2. Physical examination shows tenderness and limited range of motion in her right knee. Oral examination shows bleeding and swelling of the gums. There are diffuse petechiae around hair follicles on her abdomen and both thighs. Laboratory studies show a prothrombin time of 12 seconds, an activated partial thromboplastin time of 35 seconds, and a bleeding time of 11 minutes. Arthrocentesis of the right knee shows bloody synovial fluid. The patient’s condition is most likely associated with a defect in a reaction that occurs in which of the following cellular structures?", "answer": "Rough endoplasmic reticulum", "options": {"A": "Lysosomes", "B": "Rough endoplasmic reticulum", "C": "Nucleus", "D": "Extracellular space"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "physician", "progressive fatigue", "painful swelling of", "right knee", "3 weeks", "works", "professional ballet dancer", "I m always", "to", "shape", "performances", "5 ft 4", "tall", "kg", "99", "BMI", "kg/m2", "Physical examination shows tenderness", "limited range of motion", "right knee", "Oral examination shows bleeding", "swelling", "gums", "diffuse petechiae", "hair follicles", "abdomen", "thighs", "Laboratory studies show", "prothrombin time", "seconds", "activated partial thromboplastin time", "35 seconds", "bleeding time of", "minutes", "Arthrocentesis", "right knee shows bloody synovial fluid", "patients condition", "most likely associated with", "defect", "reaction", "occurs", "following cellular structures"]}
{"question": "A 24-year-old woman comes to the physician because she had unprotected intercourse with her boyfriend the previous day. She has had regular menses since menarche at the age of 12. Her last menstrual period was 3 weeks ago. She has no history of serious illness but is allergic to certain jewelry and metal alloys. She takes no medications. A urine pregnancy test is negative. She does not wish to become pregnant until she finishes college in six months. Which of the following is the most appropriate next step in management?", "answer": "Administer ulipristal acetate", "options": {"A": "Insert copper-containing intra-uterine device", "B": "Administer mifepristone", "C": "Administer ulipristal acetate", "D": "Administer depot medroxyprogesterone acetate"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "unprotected intercourse", "boyfriend", "previous day", "regular menses", "menarche at", "age", "last menstrual period", "3 weeks", "history", "serious illness", "allergic", "certain jewelry", "metal alloys", "takes", "medications", "urine pregnancy test", "negative", "not wish to", "pregnant", "finishes college", "six months", "following", "most appropriate next step", "management"]}
{"question": "A 27-year-old woman with a history of bipolar disorder presents for a 3-month follow-up after starting treatment with lithium. She says she has been compliant with her medication but has experienced no improvement. The patient has no other significant past medical history and takes no other medications. She reports no known allergies. The patient is afebrile, and her vital signs are within normal limits. A physical examination is unremarkable. The patient is switched to a different medication. The patient presents 2 weeks later with an acute onset rash on her torso consisting of targetoid lesions with a vesicular center. She says the rash developed 2 days ago which has progressively worsened. She also says that 1 week ago she developed fever, lethargy, myalgia, and chills that resolved in 3 days. Which of the following drugs was this patient most likely prescribed?", "answer": "Lamotrigine", "options": {"A": "Lamotrigine", "B": "Valproate", "C": "Olanzapine-fluoxetine combination (OFC)", "D": "Paroxetine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old woman", "history of bipolar disorder presents", "month follow-up", "starting treatment", "lithium", "compliant", "medication", "experienced", "improvement", "patient", "significant past medical history", "takes", "medications", "reports", "known allergies", "patient", "afebrile", "vital signs", "normal limits", "physical examination", "unremarkable", "patient", "switched", "different medication", "patient presents 2 weeks later", "acute onset rash", "torso consisting", "targetoid lesions", "vesicular center", "rash", "2 days", "worsened", "1 week", "fever", "lethargy", "myalgia", "chills", "resolved", "3 days", "following drugs", "patient", "likely prescribed"]}
{"question": "A 6-year-old boy is brought to the physician by his mother because of a 6-month history of mild episodic abdominal pain. The episodes occur every 1–2 months and last for a few hours. The pain is located in the epigastrium, radiates to his back, and is occasionally associated with mild nausea. His mother is concerned that his condition might be hereditary because his older sister was diagnosed with congenital heart disease. He is otherwise healthy and has met all developmental milestones. He is at the 75th percentile for height and the 65th percentile for weight. Physical examination shows no abdominal distention, guarding, or rebound tenderness. Which of the following congenital conditions would best explain this patient's symptoms?", "answer": "Pancreas divisum", "options": {"A": "Hypertrophic pyloric stenosis", "B": "Biliary cyst", "C": "Intestinal malrotation", "D": "Pancreas divisum"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "mother", "month history", "mild episodic abdominal pain", "episodes occur", "12 months", "last", "hours", "pain", "epigastrium", "radiates", "back", "occasionally associated with mild nausea", "mother", "concerned", "condition", "hereditary", "older sister", "diagnosed", "congenital heart disease", "healthy", "met", "developmental milestones", "percentile", "height", "percentile", "weight", "Physical examination shows", "abdominal distention", "guarding", "rebound tenderness", "following congenital conditions", "best", "patient's symptoms"]}
{"question": "A healthy, full-term 1-day-old female is being evaluated after birth and is noted to have a cleft palate and a systolic ejection murmur at the second left intercostal space. A chest radiograph is obtained which reveals a boot-shaped heart and absence of a thymus. An echocardiogram is done which shows pulmonary stenosis with a hypertrophic right ventricular wall, ventricular septal defect, and overriding of the aorta. Which of the following additional features is expected to be seen in this patient?", "answer": "Seizures due to hypocalcemia", "options": {"A": "Seizures due to hypocalcemia", "B": "Catlike cry", "C": "Hyperthyroidism from transplacental antibodies", "D": "Increased phenylalanine in the blood"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "full-term", "day old female", "evaluated after birth", "noted to", "cleft palate", "systolic ejection murmur", "second left intercostal space", "chest radiograph", "obtained", "reveals", "boot shaped heart", "absence", "thymus", "echocardiogram", "shows pulmonary", "hypertrophic", "ventricular septal defect", "overriding", "aorta", "following additional features", "expected to", "seen", "patient"]}
{"question": "A 58-year-old male with a history of obesity and hypertension presents to his primary care physician for a follow-up visit. He reports that he feels well and has no complaints. He currently takes hydrochlorothiazide. His temperature is 98.6°F (37°C), blood pressure is 135/80 mmHg, pulse is 86/min, and respirations are 17/min. His BMI is 31 kg/m2. Results of a lipid panel are: Total cholesterol is 280 mg/dl, triglycerides are 110 mg/dl, HDL cholesterol is 40 mg/dl, and LDL cholesterol is 195 mg/dl. Her physician considers starting her on atorvastatin. Which of the following will most likely decrease after initiating this medication?", "answer": "Mevalonate", "options": {"A": "Mevalonate", "B": "Acetoacetyl-CoA", "C": "Diacyglycerol", "D": "High-density lipoprotein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old male", "history of obesity", "hypertension presents", "primary care physician", "follow-up visit", "reports", "feels well", "complaints", "currently takes hydrochlorothiazide", "temperature", "98", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "BMI", "31 kg/m2", "Results", "a lipid panel", "Total cholesterol", "mg/dl", "triglycerides", "mg/dl", "HDL cholesterol", "40 mg/dl", "LDL cholesterol", "mg/dl", "physician considers starting", "atorvastatin", "following", "most likely decrease", "initiating", "medication"]}
{"question": "A 54-year-old man presents with the acute onset of seizures and hallucinations. The patient’s wife says that he had been on a camping trip a few months earlier to study bats but otherwise has not traveled recently. Past medical history is significant for hypertension, managed medically with hydralazine and enalapril. The patient’s condition rapidly deteriorates, and he passes away. An autopsy is performed and a histologic stained section of the brain is shown in the image. Which of the following receptors are targeted by the pathogen most likely responsible for this patient’s condition?", "answer": "Acetylcholine receptor", "options": {"A": "CCR5", "B": "Acetylcholine receptor", "C": "ICAM-1", "D": "GABA"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["54 year old man presents", "acute onset", "seizures", "hallucinations", "patients wife", "camping trip", "few months earlier to study bats", "not traveled recently", "Past medical history", "significant", "hypertension", "managed", "hydralazine", "enalapril", "patients condition rapidly deteriorates", "passes", "autopsy", "performed", "histologic stained section", "brain", "shown", "image", "following receptors", "targeted", "pathogen", "likely responsible", "patients condition"]}
{"question": "A 60-year-old female patient with a history of hypertension presents to an outpatient office for regular check-up and is found to have hypertriglyceridemia. Her physician prescribes high-dose niacin and recommends taking the medication along with aspirin. The side effect the physician is trying to avoid is thought to be mediated by what mechanism?", "answer": "Release of prostaglandins", "options": {"A": "Bile deposition in the dermis", "B": "Release of prostaglandins", "C": "Mast cell degranulation", "D": "T cell activation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old female patient", "history of hypertension presents", "outpatient office", "regular check-up", "found to", "hypertriglyceridemia", "physician", "high-dose niacin", "recommends taking", "medication", "aspirin", "side effect", "physician", "to", "thought to", "mediated", "mechanism"]}
{"question": "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:\nHemoglobin 14 g/dL\nLeukocyte count 10,000/mm3\nPlatelet count 146,000/mm3\nSerum\nGlucose 150 mg/dL\nAlbumin 3.2 g/dL\nTotal bilirubin 1.5 mg/dL\nAlkaline phosphatase 75 U/L\nAST 95 U/L\nALT 73 U/L\nHIV negative\nHepatitis B surface antigen negative\nHepatitis C antibody positive\nHCV RNA positive\nHCV genotype 1\nA 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?\"", "answer": "Sofosbuvir and ledipasvir therapy", "options": {"A": "Sofosbuvir and ledipasvir therapy", "B": "Tenofovir and velpatasvir therapy", "C": "Interferon and ribavirin therapy", "D": "Tenofovir and entecavir therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "elevated liver function tests", "found", "routine screening", "occasional headaches", "past year", "feels well", "patient reports", "involved", "severe car accident 30 years", "not smoke", "drink alcohol", "never used illicit intravenous drugs", "takes", "medications", "known allergies", "father", "history of alcoholism", "died of liver cancer", "patient appears thin", "temperature", "pulse", "100 min", "blood pressure", "70 mm Hg", "Physical examination shows", "abnormalities", "Laboratory studies show", "Leukocyte", "Albumin", "B", "antigen", "genotype", "liver biopsy", "performed", "shows mononuclear infiltrates", "limited", "portal tracts", "periportal hepatocyte necrosis", "following", "most appropriate next step", "management"]}
{"question": "A 44-year-old woman with hypothyroidism comes to the physician because of a 1-month history of tingling in her feet and poor balance. Her only medication is levothyroxine. Physical examination shows conjunctival pallor and an ataxic gait. Proprioception and sense of vibration are decreased in her toes bilaterally. Laboratory studies show macrocytic anemia and normal thyroid hormone levels. Histological evaluation of tissue samples obtained by esophagogastroduodenoscopy reveals atrophic changes of the gastric body and fundus with normal antral mucosa. Which of the following structures is most likely being targeted by antibodies in this patient?", "answer": "Parietal cells", "options": {"A": "Islet cell cytoplasm", "B": "Deamidated gliadin peptide", "C": "Parietal cells", "D": "Smooth muscle"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "hypothyroidism", "physician", "month history", "tingling", "feet", "poor balance", "only medication", "levothyroxine", "Physical examination shows conjunctival pallor", "ataxic gait", "Proprioception", "sense", "vibration", "decreased", "toes", "Laboratory studies show macrocytic anemia", "normal thyroid", "Histological evaluation", "tissue samples obtained", "esophagogastroduodenoscopy reveals atrophic changes", "gastric body", "fundus", "normal antral mucosa", "following structures", "most likely", "targeted by antibodies", "patient"]}
{"question": "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?", "answer": "ADH resistance in the renal collecting ducts", "options": {"A": "Hypothalamic over-production of antidiuretic hormone (ADH)", "B": "Decreased production of ADH", "C": "ADH resistance in the renal collecting ducts", "D": "Increased sodium reabsorption and potassium excretion"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female", "of frequent", "large volume urination", "affects", "sleep", "to frequently wake up", "night to", "increased thirst", "past medical history", "significant", "bipolar disorder", "treated with lithium", "3 years", "Serum osmolality", "425 mOsm/kg", "urine osmolality", "mOsm/kg", "following best", "patients serum", "urine osmolality"]}
{"question": "An 8-year-old girl presents to her pediatrician with intensely pruritic lesions over her buttocks, as shown. These lesions occur intermittently but have worsened over time. Her medical history is remarkable for iron deficiency, for which she is on ferrous sulfate. The patient has also experienced intermittent episodes of mild diarrhea, previously diagnosed as lactose intolerance. Her height is at the 30th percentile and weight is at the 25th percentile for age and sex. An immunoglobulin A (IgA) tissue transglutaminase titer is 5 times the upper limit of normal. Which of the following is the most likely cause of this patient's condition?", "answer": "Celiac disease", "options": {"A": "Crohn’s disease", "B": "Celiac disease", "C": "Common variable immune deficiency", "D": "Henoch-Schonlein purpura"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl presents", "pediatrician", "lesions", "buttocks", "shown", "lesions occur", "worsened", "time", "medical history", "iron deficiency", "ferrous sulfate", "patient", "experienced intermittent episodes of mild diarrhea", "diagnosed", "lactose intolerance", "height", "percentile", "weight", "percentile", "age", "sex", "immunoglobulin A", "tissue transglutaminase titer", "5 times", "upper limit of normal", "following", "most likely cause", "patient's condition"]}
{"question": "A 64-year-old man comes to the emergency department because of a 2-day history of lower back pain, fever, and chills. He has had nausea but no vomiting during this time. He has hypertension, chronic kidney disease, and type 2 diabetes mellitus. Three months ago, he underwent amputation of his left third toe because of a non-healing ulcer. He has smoked a pack of cigarettes daily for 48 years. Current medications include hydrochlorothiazide, metoprolol, and insulin. His temperature is 39.4°C (102.9°F), pulse is 102/min, blood pressure is 150/94 mm Hg, and respirations are 18/min. Examination shows a 1-cm (0.4-in) round ulcer on the sole of his right foot. There is costovertebral angle tenderness on the left side. The abdomen is soft. Laboratory studies show:\nHemoglobin 11.5 g/dL\nLeukocyte count 19,000/mm3\nSerum\nNa+ 140 mEq/L\nCl− 102 mEq/L\nK+ 5.0 mEq/L\nHCO3− 25 mEq/L\nUrea nitrogen 65 mg/dL\nCreatinine 2.4 mg/dL\nGlucose 240 mg/dL\nUrine\nBlood 1+\nProtein 1+\nWBC 100/hpf\nNitrite 2+\nWBC casts numerous\nUrine and blood samples for culture and sensitivity tests are obtained. Which of the following is the most appropriate next step in management?\"", "answer": "Inpatient treatment with intravenous ciprofloxacin", "options": {"A": "Inpatient treatment with intravenous ciprofloxacin", "B": "Outpatient treatment with oral levofloxacin", "C": "Outpatient treatment with trimethoprim-sulfamethoxazole", "D": "Initiate hemodialysis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["64 year old man", "emergency department", "of", "2-day history", "lower back pain", "fever", "chills", "nausea", "vomiting", "time", "hypertension", "chronic kidney disease", "type 2 diabetes mellitus", "Three months", "amputation of", "left third toe", "non", "smoked", "pack", "cigarettes daily", "48 years", "Current medications include hydrochlorothiazide", "metoprolol", "insulin", "temperature", "4C", "9F", "pulse", "min", "blood pressure", "mm Hg", "respirations", "min", "Examination shows", "0.4", "round ulcer", "sole of", "right foot", "costovertebral angle tenderness", "left side", "abdomen", "soft", "Laboratory studies show", "dL", "0", "65 mg", "Urine", "WBC", "casts numerous Urine", "blood samples for culture", "sensitivity tests", "obtained", "following", "most appropriate next step", "management"]}
{"question": "A 56-year-old man with a history of pancreatic cancer presents to the surgical intensive care unit following a pancreaticoduodenectomy. Over the next 3 days, the patient's drainage output is noted to exceed 1 liter per day. In the early morning of postoperative day 4, the nurse states that the patient is difficult to arouse. His temperature is 99.5°F (37.5°C), blood pressure is 107/88 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. His skin and mucous membranes are dry on physical exam. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 154 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 27 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\n\nWhich of the following is the best next step in management?", "answer": "0.9% saline IV", "options": {"A": "0.9% saline IV", "B": "5% dextrose IV", "C": "5% dextrose IV with 0.45% saline IV", "D": "Oral free water replacement"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "history of pancreatic cancer presents", "surgical intensive care unit following", "pancreaticoduodenectomy", "next", "days", "patient's drainage output", "noted to", "1 liter per day", "early morning", "postoperative day 4", "nurse states", "patient", "difficult", "temperature", "99", "blood pressure", "88 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "skin", "mucous membranes", "dry", "physical exam", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "27 mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL", "following", "best next step", "management"]}
{"question": "A 46-year-old woman comes to the physician because of a 3-day history of diarrhea, moderate abdominal pain, and weakness. Her symptoms began on the return flight from a 2-week yoga retreat in India, where she stayed at a resort. She was mildly nauseous as she boarded the flight, and diarrhea followed immediately after eating the in-flight meal. Since then, she has had up to five watery stools daily. She has a 1-year history of gastroesophageal reflux disease and is allergic to shellfish. Her only medication is ranitidine. She appears lethargic. Her temperature is 37°C (98.6°F), pulse is 70/min, and blood pressure is 115/72 mm Hg. Abdominal examination shows diffuse tenderness with no guarding or rebound. Bowel sounds are hyperactive. Which of the following is the most likely pathogen?", "answer": "Enterotoxigenic Escherichia coli", "options": {"A": "Giardia intestinalis", "B": "Shigella species", "C": "Staphylococcus aureus", "D": "Enterotoxigenic Escherichia coli"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "3-day history", "diarrhea", "moderate abdominal", "weakness", "symptoms began", "return flight", "2 week yoga", "India", "resort", "mildly nauseous", "boarded", "flight", "diarrhea followed immediately", "eating", "in flight meal", "then", "up to five watery stools daily", "year history of gastroesophageal reflux disease", "allergic", "shellfish", "only medication", "ranitidine", "appears lethargic", "temperature", "98", "pulse", "70 min", "blood pressure", "72 mm Hg", "Abdominal examination shows diffuse tenderness", "guarding", "Bowel sounds", "hyperactive", "following", "most likely pathogen"]}
{"question": "A research group has created a novel screening test for a rare disorder. A robust clinical trial is performed in a group of 100 subjects comparing the new screening test against the gold standard. The results are given in the table below:\nScreening test\\gold standard Disease present Disease absent\nPositive 45 15\nNegative 5 35\nWhich of the following is most correct regarding the statistical power of this new screening test?", "answer": "If the sensitivity of this screening test were decreased, the statistical power would decrease.", "options": {"A": "Repeating the study would have no effect on the statistical power of the screening test.", "B": "The power of the test is 0.8.", "C": "If the specificity of this screening test were increased, the statistical power would increase.", "D": "If the sensitivity of this screening test were decreased, the statistical power would decrease."}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["research group", "created", "novel screening test for", "rare disorder", "robust clinical trial", "performed", "a group", "100 subjects comparing", "new screening test", "gold standard", "results", "given", "table", "Screening test gold standard Disease present", "absent Positive", "Negative 5", "following", "most correct", "statistical power", "new screening test"]}
{"question": "A 25-year-old woman presents to her new family physician for a follow-up appointment. She previously presented with itching, as well as frequent and painful urination. A vaginal swab was taken and sent to the laboratory to confirm the diagnosis. Diplococci were seen on Gram stain and were grown on Thayer-Martin agar. When discussing her infection, the patient says that she uses safe sex practices. Her history is significant for meningitis and for infection with Streptococcus pneumoniae. The physician discusses that the reason behind these infections comes from a defect in the innate immune system. Which of the following best describes the component that is likely deficient in this patient?", "answer": "Creates pores in the cell membrane", "options": {"A": "Plays a role in angioedema", "B": "Degraded by C1 esterase inhibitor", "C": "Creates pores in the cell membrane", "D": "Induces the alternative complement pathway"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "new family physician", "follow-up appointment", "presented", "itching", "frequent", "painful urination", "vaginal swab", "taken", "sent", "laboratory to confirm", "diagnosis", "Diplococci", "seen", "Gram stain", "Thayer-Martin agar", "discussing", "infection", "patient", "uses safe sex practices", "history", "significant", "meningitis", "infection", "Streptococcus pneumoniae", "physician discusses", "reason", "infections", "defect", "immune system", "following best", "component", "likely deficient", "patient"]}
{"question": "A 55-year-old woman with papillary thyroid carcinoma underwent total thyroidectomy. She has no significant medical history. On postoperative day 1, she develops perioral numbness and a tingling sensation, along with paresthesia of the hands and feet. The physical examination reveals that she is anxious and confused. Her pulse is 90/min, the blood pressure is 110/80 mm Hg, the respirations are 22/min, and the temperature is 36.7°C (98.0°F). Latent tetany (carpal spasm) is evident in the right arm. This is observed when the sphygmomanometer cuff pressure is raised above the systolic blood pressure and held for 3 minutes. The laboratory test results are as follows:\nSerum calcium 6.7 mg/dL\nSerum sodium 143 mEq/L\nSerum potassium 4.4 mEq/L\nSerum creatinine 0.9 mg/dL\nBlood urea 16 mg/dL\nSerum magnesium 1.1 mEq/L\nWhat is the most likely cause of this condition?", "answer": "Inadvertent surgical removal of parathyroid glands", "options": {"A": "Inadvertent surgical removal of parathyroid glands", "B": "DiGeorge syndrome", "C": "Chronic hypomagnesemia", "D": "Hungry bone syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old woman", "papillary thyroid carcinoma", "total thyroidectomy", "significant medical history", "postoperative day 1", "perioral numbness", "tingling sensation", "paresthesia of", "hands", "feet", "physical examination reveals", "anxious", "confused", "pulse", "90 min", "blood pressure", "80 mm Hg", "respirations", "min", "temperature", "36", "98", "Latent tetany", "carpal spasm", "evident", "right arm", "observed", "sphygmomanometer cuff pressure", "raised", "systolic", "held", "minutes", "laboratory test results", "follows", "Serum", "mg", "L", "potassium", "creatinine 0.9 mg", "magnesium", "most likely cause", "condition"]}
{"question": "A 16-year-old boy is brought to the physician by his parents for the evaluation of fatigue for several weeks. The parents report that their son quit doing sports at school because of low energy. The patient's academic performance has declined recently. He spends most of his time in the basement playing video games and eating bowls of cereal. He has no history of serious illness. His mother has Hashimoto's thyroiditis and his father has major depressive disorder. The patient does not smoke or drink alcohol. His vital signs are within normal limits. Examination shows conjunctival pallor, inflammation and fissuring of the corners of the mouth, and concavity of the finger nails. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 11.5 g/dL\nMean corpuscular volume 76 μm3\nPlatelet count 290,000/mm3\nRed cell distribution width 18% (N = 13%–15%)\nLeukocyte count 7,000/mm3\nWhich of the following is the most appropriate initial step in treatment?\"", "answer": "Iron supplementation", "options": {"A": "Regular blood transfusions", "B": "Methylphenidate", "C": "Iron supplementation", "D": "Allogenic stem cell transplantation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "parents", "evaluation", "fatigue", "several weeks", "parents report", "son quit", "sports", "school", "low energy", "patient", "cademic ", "ecently.", "pends  ost of ", "ime ", "asement  laying  ideo games ", "ating  owls ", "ereal.", "istory ", "erious  llness.", "other ", "ashimoto'", "yroiditis a", "ther h", "jor depressive disorder. ", "tient d", "t s oke o", "ink alcohol. ", "tal signs a", "rmal limits. ", "amination s ows c njunctival p llor, ", "flammation a", "ssuring o  t", "rners o", "uth, ", "ncavity o  t", "nger nails. ", "amination s ows n", "normalities. ", "boratory studies s ow: ", "moglobin 1", "d", "an corpuscular volume 7", " P atelet count 2", "3 R d cell distribution width 1", "=", "ukocyte count 7", "3 W", "llowing i", "st a propriate i itial s ep i", "eatment?\""]}
{"question": "A 78-year-old man is brought to the emergency department because of a 1-day history of painful enlarging bruises and skin ulceration over his thighs and external genitalia. He has type 2 diabetes mellitus, mitral regurgitation, and atrial fibrillation. Three days ago, he was started on treatment with warfarin. His only other medications are metformin and lisinopril. His temperature is 37.8°C (100.0°F), pulse is 108/min and irregularly irregular, and blood pressure is 155/89 mm Hg. Examination of the skin shows large purpura, hemorrhagic bullae, and areas of skin necrosis over his anterior legs, gluteal region, and penis. This patient is most likely to benefit from treatment with which of the following?", "answer": "Protein C concentrate", "options": {"A": "Hyperbaric oxygen", "B": "Protein C concentrate", "C": "Argatroban", "D": "Tranexamic acid"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "1-day history", "painful enlarging bruises", "skin", "thighs", "external genitalia", "type 2 diabetes mellitus", "mitral regurgitation", "atrial fibrillation", "Three days", "started on", "warfarin", "only", "medications", "metformin", "lisinopril", "temperature", "100", "pulse", "min", "irregular", "blood pressure", "mm Hg", "Examination of", "skin shows large purpura", "hemorrhagic bullae", "areas of skin necrosis", "anterior legs", "gluteal region", "penis", "patient", "most likely to benefit", "treatment", "following"]}
{"question": "A 15-year-old boy is brought to the physician for evaluation of a learning disability. His teachers have reported hyperactivity during class, difficulties with social interaction, and poor scores on reading and writing assessments. Molecular analysis shows an increased number of CGG trinucleotide repeats. Which of the following findings are most likely to be seen on physical examination of this patient?", "answer": "Long face and large everted ears", "options": {"A": "Frontal balding and cataracts", "B": "Long face and large everted ears", "C": "Almond-shaped eyes and downturned mouth", "D": "Thin upper lip and receding chin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "evaluation", "learning", "teachers", "reported hyperactivity", "class", "difficulties", "social", "poor scores", "reading", "writing assessments", "Molecular analysis shows", "increased number", "CGG trinucleotide repeats", "following findings", "most likely to", "seen", "physical examination", "patient"]}
{"question": "A 65-year-old woman presented to the emergency room due to progressive dyspnea. She is a known hypertensive but is poorly compliant with medications. The patient claims to have orthopnea, paroxysmal nocturnal dyspnea, and easy fatigability. On physical examination, the blood pressure is 80/50 mm Hg. There is prominent neck vein distention. An S3 gallop, bibasilar crackles, and grade 3 bipedal edema were also detected. A 2d echo was performed, which showed a decreased ejection fraction (32%). Which of the following drugs should not be given to this patient?", "answer": "Metoprolol", "options": {"A": "Furosemide", "B": "Nesiritide", "C": "Metoprolol", "D": "Digoxin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["65 year old woman presented", "emergency room", "progressive dyspnea", "known hypertensive", "poorly compliant", "medications", "patient", "to", "orthopnea", "paroxysmal nocturnal dyspnea", "easy fatigability", "physical examination", "blood pressure", "80 50 mm Hg", "prominent neck vein distention", "S3 gallop", "crackles", "grade 3", "edema", "detected", "2d echo", "performed", "showed", "decreased ejection fraction", "following drugs", "not", "given", "patient"]}
{"question": "A 49-year-old woman is brought to the emergency department with progressive dyspnea and cough which she developed approx. 8 hours ago. 2 weeks ago she had a prophylactic ovariectomy because of a family history of ovarian cancer. She is known to have type 2 diabetes mellitus and stage 1 hypertension, but she does not take her antihypertensives because she is not concerned about her blood pressure. Also, she has a history of opioid abuse. She takes metformin 1000 mg and aspirin 81 mg. She has been smoking 1 pack of cigarettes per day for 22 years. Her vital signs are as follows: blood pressure 155/80 mm Hg, heart rate 101/min, respiratory rate 31/min, and temperature 37.9℃ (100.2℉). Blood saturation on room air is 89%. On examination, the patient is dyspneic and acrocyanotic. Lung auscultation reveals bilateral rales over the lower lobes. A cardiac examination is significant for S2 accentuation best heard in the second intercostal space at the left sternal border and S3 presence. There is no leg edema. Neurological examination is within normal limits. Arterial blood gases analysis shows the following results:\npH 7.49\nPaO2 58 mm Hg\nPaCO2 30 mm Hg\nHCO3-  22 mEq/L\nBased on the given data, which of the following could cause respiratory failure in this patient?", "answer": "Increased alveolar dead space due to absent perfusion of certain alveoli", "options": {"A": "Increased alveolar dead space due to absent perfusion of certain alveoli", "B": "Alveolar fibrosis", "C": "Depression of the respiratory center via opioid receptors activation", "D": "Decreased V/Q due to bronchial obstruction"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "progressive dyspnea", "cough", "8 hours", "2 weeks", "prophylactic ovariectomy", "of", "family history of ovarian cancer", "known to", "type 2 diabetes mellitus", "stage 1 hypertension", "not take", "antihypertensives", "not concerned", "blood pressure", "history of opioid abuse", "takes metformin", "mg", "aspirin 81 mg", "smoking 1 pack", "cigarettes", "day", "years", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate 31 min", "temperature", "100", "Blood saturation", "room air", "examination", "patient", "dyspneic", "Lung auscultation reveals bilateral rales", "lower lobes", "cardiac examination", "significant", "S2", "best heard", "second intercostal space", "left sternal border", "S3 presence", "leg edema", "Neurological examination", "normal limits", "Arterial blood gases analysis shows", "following results", "pH 7", "PaO2 58 mm Hg", "30", "HCO3", "mEq/L Based", "data", "following", "cause respiratory failure", "patient"]}
{"question": "A 27-year-old woman presents to the emergency department with acute onset bloody diarrhea. The patient has had severe abdominal pain throughout her entire life with occasional episodes of bloody diarrhea. She has recently lost 7 pounds and has felt generally ill for the past 2 days. She has a past medical history of generalized seizures with her most recent one having occurred 5 days ago. One month ago, the patient was treated for impetigo. The patient admits to occasional cocaine use and binge drinking. Her temperature is 98.7°F (37.1°C), blood pressure is 107/58 mmHg, pulse is 127/min, respirations are 16/min, and oxygen saturation is 99% on room air. Physical exam is notable for diffuse abdominal tenderness and guaiac positive stools. Laboratory values are ordered as seen below.\n\nHemoglobin: 9 g/dL\nHematocrit: 30%\nLeukocyte count: 9,400/mm^3 with normal differential\nPlatelet count: 199,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 101 mEq/L\nK+: 4.9 mEq/L\nHCO3-: 25 mEq/L\nBUN: 37 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.8 mg/dL\nAST: 62 U/L\nALT: 80 U/L\nBlood alcohol: .15 g/dL\n\nUrine:\nColor: Yellow\nProtein: Positive\nCocaine: Positive\nMarijuana: Positive\n\nWhich of the following is the best explanation for this patient's laboratory findings?", "answer": "Protein deposition", "options": {"A": "Alcohol-induced liver injury", "B": "Immune response to streptococcal infection", "C": "Intestinal IgA deficiency", "D": "Protein deposition"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old woman presents", "emergency department", "acute onset bloody diarrhea", "patient", "severe abdominal", "entire life", "occasional episodes of bloody diarrhea", "recently lost", "pounds", "felt", "ill", "past 2 days", "past medical generalized seizures", "most recent one", "occurred 5 days", "One month", "patient", "treated", "impetigo", "patient admits", "occasional cocaine use", "binge drinking", "temperature", "98", "blood pressure", "58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "diffuse abdominal tenderness", "guaiac positive stools", "Laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "30", "Leukocyte count", "400 mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "mEq/L K", "4", "mEq/L HCO3", "mEq/L", "mg/dL Glucose", "99 mg/dL Creatinine", "1.8 mg/dL AST", "62 U/L ALT", "80 U/L Blood alcohol", "g/dL", "Urine", "Color", "Yellow Protein", "Positive Cocaine", "Positive Marijuana", "Positive", "following", "best explanation", "patient's laboratory findings"]}
{"question": "A 45-year-old Caucasian male presents to a gastroenterologist complaining of heartburn and difficulty swallowing. He recalls that he has been told by his primary care physician that he suffers from gastroesophageal reflux disease (GERD). The gastroenterologist decides to perform an upper endoscopy with biopsy. Which of the following findings would be consistent with Barrett's esophagus?", "answer": "A small region of red, velvet-like mucosa in the lower esophagus", "options": {"A": "Presence of Paneth cells in the lower esophagus", "B": "Metaplasia in the upper esophagus", "C": "A small region of red, velvet-like mucosa in the lower esophagus", "D": "Esophageal varices"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old Caucasian male presents", "gastroenterologist", "heartburn", "difficulty swallowing", "recalls", "primary care physician", "suffers", "gastroesophageal reflux disease", "gastroenterologist", "to perform", "upper", "biopsy", "following findings", "consistent with Barrett's esophagus"]}
{"question": "A 16-year-old female patient with a history of mental retardation presents to your clinic with her mother. The mother states that she wants her daughter to have a bilateral tubal ligation after she recently discovered her looking at pornographic materials. She states that her daughter is not capable of understanding the repercussions of sexual intercourse, and that she does not want her to be burdened with a child that she would not be able to raise. Upon discussions with the patient, it is clear that she is not able to understand that sexual intercourse can lead to pregnancy. What should your next step be?", "answer": "Refuse the procedure because it violates the ethical principle of autonomy", "options": {"A": "Schedule the patient for the requested surgery", "B": "Wait until the patient is 18 years old, and then schedule for surgery", "C": "Refuse the procedure because it violates the ethical principle of autonomy", "D": "Refuse the procedure because it is unlikely that the patient will get pregnant"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female", "history", "mental retardation presents", "clinic", "mother", "mother states", "daughter to", "bilateral tubal ligation", "recently discovered", "looking", "pornographic materials", "states", "daughter", "not capable", "understanding", "sexual intercourse", "not", "to", "burdened", "child", "not", "able to", "discussions", "patient", "clear", "not able to understand", "sexual intercourse", "lead", "pregnancy", "next step"]}
{"question": "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?", "answer": "Inhibit phagocytosis", "options": {"A": "Cleave immunoglobulin", "B": "Inhibit phagocytosis", "C": "Inhibit ribosomal function", "D": "Trigger widespread inflammation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care provider", "malaise", "returned", "research trip", "Madagascar", "weeks", "since", "worsening fever", "maximum temperature", "reports", "swelling", "neck", "groin", "works", "zoologist", "rural Madagascar studying", "rare species", "lemur", "past medical history", "notable", "hypertension", "gout", "takes lisinopril", "allopurinol", "temperature", "9F", "3C", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "exam", "painful erythematous cervical", "axillary", "inguinal lymphadenopathy", "Black hemorrhagic eschars", "noted", "fingertips", "pathogen responsible", "patients condition", "virulence factor", "following functions"]}
{"question": "A 45-year-old African-American male presents to the family medicine physician to assess the status of his diabetes. After reviewing the laboratory tests, the physician decides to write the patient a prescription for miglitol and states that it must be taken with the first bite of the meal. Which of the following bonds will no longer be cleaved when the patient takes miglitol?", "answer": "Glycosidic bonds", "options": {"A": "Phosphodiester bonds", "B": "Glycosidic bonds", "C": "Cystine bonds", "D": "Hydrogen bonds"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old African-American male presents", "family medicine physician to assess", "status", "diabetes", "reviewing", "laboratory tests", "physician", "to write", "patient", "prescription", "miglitol", "states", "taken", "first bite", "meal", "following", "longer", "cleaved", "patient takes miglitol"]}
{"question": "A previously healthy 24-year-old man comes to the physician 1 day after the onset of burning pain, swelling, and multiple blisters over the left index finger. He works as a dental assistant and is concerned about not being able to work. The patient wonders if the symptoms might be related to a hunting trip he returned from 1 week ago because he remembers seeing a lot of poison oak. He is sexually active with one female partner, and they do not use condoms. His father has a history of thromboangiitis obliterans. He has smoked one pack of cigarettes daily for 5 years. He drinks two to four beers on social occasions. Vital signs are within normal limits. Physical examination shows swelling and erythema of the pulp space of the left index finger; there are multiple 3-mm vesicles. Laboratory studies show a leukocyte count of 12,000 cells/mm3. In addition to supportive therapy, which of the following is the most appropriate next step in management?", "answer": "Oral acyclovir", "options": {"A": "Oral acyclovir", "B": "Oral cephalexin", "C": "Smoking cessation", "D": "Washing thoroughly\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old man", "physician 1 day", "onset", "burning", "swelling", "multiple blisters", "left index finger", "works", "dental assistant", "concerned", "not", "able to work", "patient", "symptoms", "related", "hunting trip", "returned", "1 week", "remembers seeing", "lot", "poison oak", "sexually active", "one female partner", "not use condoms", "father", "history", "thromboangiitis obliterans", "smoked one pack", "cigarettes daily", "5 years", "drinks two", "four beers", "social occasions", "Vital signs", "normal", "Physical examination shows swelling", "erythema of", "pulp space", "left index finger", "multiple", "mm vesicles", "Laboratory studies show", "leukocyte count", "cells/mm3", "supportive therapy", "following", "most appropriate next step", "management"]}
{"question": "A 63-year-old man presents to the ambulatory medical clinic with symptoms of dysphagia and ‘heartburn’, which he states have become more troublesome over the past year. His past medical history is significant for hypertension and GERD. He takes lisinopril for hypertension and has failed multiple different therapies for his GERD. On physical exam, he is somewhat tender to palpation over his upper abdomen. Barium swallow demonstrates a subdiaphragmatic gastroesophageal junction, with herniation of the gastric fundus into the left hemithorax. Given the following options, what is the most appropriate next step in the management of this patient’s underlying condition?", "answer": "Surgical gastropexy", "options": {"A": "Lifestyle modification", "B": "Combined antacid therapy", "C": "Continue on Omeprazole", "D": "Surgical gastropexy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old man presents", "ambulatory medical clinic", "symptoms", "dysphagia", "heartburn", "states", "more", "past year", "past medical history", "significant", "hypertension", "GERD", "takes lisinopril", "hypertension", "failed multiple different therapies", "GERD", "physical exam", "somewhat tender", "palpation", "upper abdomen", "Barium swallow demonstrates", "gastroesophageal junction", "herniation", "gastric fundus", "left hemithorax", "Given", "following options", "most appropriate next step", "management", "patients", "condition"]}
{"question": "A 63-year-old man is admitted to the intensive care unit for hemodynamic instability. Several days prior, he had been swimming in the Gulf coast when he stepped on a sharp rock and cut his right foot. Three days ago, the patient presented to the emergency room after noticing painful redness spreading along his skin up from his right foot and was subsequently admitted for antibiotic treatment. Currently, his temperature is 101.8°F (38.8°C), blood pressure is 84/46 mmHg with a mean arterial pressure of 59 mmHg, pulse is 104/min, and respirations are 14/min. His telemetry shows sinus tachycardia. His blood cultures are pending, but Gram stain demonstrated gram-negative bacilli. Which of the following best describes the form of shock and the skin exam?", "answer": "Distributive shock with warm skin", "options": {"A": "Distributive shock with warm skin", "B": "Hypovolemic shock with warm skin", "C": "Neurogenic shock with cold skin", "D": "Obstructive shock with cold skin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["63 year old man", "admitted to", "intensive care unit", "hemodynamic instability", "days prior", "swimming", "stepped", "sharp rock", "cut", "right foot", "Three days", "patient presented", "emergency room", "painful redness spreading", "skin", "right foot", "admitted", "antibiotic treatment", "Currently", "temperature", "blood pressure", "84", "mmHg", "mean arterial pressure", "59", "pulse", "min", "respirations", "min", "telemetry shows sinus tachycardia", "blood cultures", "Gram", "negative", "following best", "form", "shock", "skin exam"]}
{"question": "A 24-year-old female presents to the emergency department with a chief complaint of an inability to urinate. She states that this has been one of many symptoms she has experienced lately. At times she has had trouble speaking and has noticed changes in her vision however these episodes occurred over a month ago and have resolved since then. Two days ago she experienced extreme pain in her face that was exacerbated with brushing her teeth and plucking out facial hairs. The patient has no relevant past medical history, however, the patient admits to being sexually abused by her boyfriend for the past year. Her current medications include ibuprofen for menstrual cramps. On physical exam it is noted that leftward gaze results in only the ipsilateral eye gazing leftward. The patient's initial workup is started in the emergency department. Her vital signs are within normal limits and you note a pale and frightened young lady awaiting further care. Which of the following is the best initial test for this patient's chief complaint?", "answer": "Head MRI", "options": {"A": "Head CT", "B": "Head MRI", "C": "Lumbar puncture", "D": "Domestic abuse screening and exploring patient's life stressors"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female presents", "emergency department", "chief complaint", "to", "states", "one", "symptoms", "experienced", "times", "speaking", "changes", "vision", "episodes occurred", "month", "resolved since then", "Two days", "experienced extreme pain", "face", "exacerbated", "brushing", "teeth", "plucking out facial hairs", "patient", "relevant past medical history", "patient admits", "sexually abused", "boyfriend", "past year", "current medications include ibuprofen", "menstrual cramps", "physical exam", "noted", "gaze results", "only", "ipsilateral eye gazing", "patient's initial workup", "started", "emergency department", "vital signs", "normal limits", "note", "pale", "frightened young", "further care", "following", "best initial test", "patient's chief complaint"]}
{"question": "A 54-year-old woman is brought to the physician by her brother for confusion and agitation. She is unable to personally give a history. Her brother says she has a problem with alcohol use and that he found an empty bottle of vodka on the counter at her home. She appears disheveled. Her temperature is 37°C (98.6°F), pulse is 85/min, and blood pressure is 140/95 mm Hg. On mental status examination, she is confused and oriented only to person. She recalls 0 out of 3 words after 5 minutes. She cannot perform serial sevens and is unable to repeat seven digits forward and five in reverse sequence. Neurologic examination shows horizontal nystagmus on lateral gaze. She has difficulty walking without assistance. Laboratory studies show:\nHemoglobin 11 g/dL\nMean corpuscular volume 110 μm3\nPlatelet count 280,000/mm3\nWhich of the following is most appropriate initial treatment for this patient?\"", "answer": "Intravenous thiamine", "options": {"A": "Intravenous thiamine", "B": "Oral naltrexone", "C": "Intravenous vitamin B12", "D": "Intravenous glucose\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["54 year old woman", "brought", "physician", "brother", "confusion", "agitation", "unable", "give", "history", "brother", "problem", "alcohol use", "found", "empty bottle", "vodka", "counter", "home", "appears", "temperature", "98", "pulse", "85 min", "blood pressure", "95 mm Hg", "mental", "confused", "oriented only", "person", "recalls 0 out", "3 words", "5 minutes", "perform serial", "unable to repeat seven digits forward", "five", "reverse sequence", "Neurologic examination shows horizontal nystagmus on lateral gaze", "difficulty", "assistance", "Laboratory studies show", "Hemoglobin", "g Mean corpuscular volume", "m3 Platelet count", "mm3", "following", "most appropriate initial treatment", "patient"]}
{"question": "An 18-year-old woman makes an appointment with a gynecologist for her first gynecologic examination. She did not disclose her past medical history, but her sexual debut occurred with her boyfriend 3 weeks ago. She is now complaining of a yellow-green, diffuse, malodorous vaginal discharge that she noticed 1 week ago for the first time. She also reported mild pelvic and abdominal pain. cervical motion tenderness was noted during the pelvic examination. The gynecologist also noticed a pink and inflamed nulliparous cervix with a preponderance of small red punctate spots. There was a frothy white discharge with a malodorous odor in the vaginal vault. A wet mount was prepared for a light microscopic examination, which revealed numerous squamous cells and motile organisms. The gynecologist concluded that this was a sexually-transmitted infection. What is the causative organism?", "answer": "Trichomonas vaginalis", "options": {"A": "Chlamydia trachomatis", "B": "Ureaplasma urealyticum", "C": "Trichomonas vaginalis", "D": "Enterobius vermicularis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman makes", "appointment", "gynecologist", "first gynecologic examination", "not", "past medical history", "sexual", "occurred", "boyfriend", "weeks", "now", "yellow-green", "diffuse", "vaginal discharge", "1", "first time", "reported mild pelvic", "abdominal pain", "cervical motion tenderness", "noted", "pelvic examination", "gynecologist", "pink", "inflamed nulliparous cervix", "small red punctate spots", "frothy white discharge", "odor", "vaginal vault", "wet mount", "prepared", "light microscopic examination", "revealed numerous squamous cells", "motile organisms", "gynecologist concluded", "sexually-transmitted infection", "organism"]}
{"question": "A 70-year-old man is brought to the physician by his daughter because of increasing forgetfulness over the past 3 years. Initially, he used to forget his children's names or forget to lock the house door. During the past year, he has gotten lost twice while returning from the grocery store and was unable to tell passersby his address. One time, he went to the park with his granddaughter and returned home alone without realizing he had forgotten her. His daughter says that over the past year, he has withdrawn himself from social gatherings and avoids making conversation. He does not sleep well at night. His daughter has hired a helper to cook and clean his home. On mental status examination, he is oriented only to person. He describes his mood as fair. Short- and long-term memory deficits are present. He appears indifferent about his memory lapses and says this is normal for someone his age. The most appropriate initial pharmacotherapy for this patient is a drug that acts on which of the following neurotransmitters?", "answer": "Acetylcholine", "options": {"A": "γ-aminobutyric acid", "B": "Acetylcholine", "C": "Dopamine", "D": "Glutamate"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["70 year old man", "brought", "physician", "daughter", "increasing forgetfulness", "past", "years", "Initially", "used to forget", "children's names", "forget to lock", "house door", "past year", "gotten lost twice", "returning", "grocery store", "unable to", "address", "One time", "park", "granddaughter", "returned home alone", "forgotten", "daughter", "past year", "withdrawn", "social gatherings", "making conversation", "not sleep well", "night", "daughter", "hired", "cook", "clean", "home", "mental", "oriented only", "person", "mood", "fair", "Short", "long-term memory deficits", "present", "appears indifferent", "memory lapses", "normal", "age", "most appropriate initial pharmacotherapy", "patient", "drug", "acts", "following neurotransmitters"]}
{"question": "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?", "answer": "Atropine and pralidoxime", "options": {"A": "Succinylcholine", "B": "Inhaled ipratropium and oxygen", "C": "Atropine and pralidoxime", "D": "Inhaled albuterol and oxygen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old mechanic presents", "emergency department", "of acute-onset shortness", "breath", "repairing", "tractor", "neighbor", "patient denies", "history of asthma", "respiratory symptoms", "not smoke", "temperature", "99", "pulse", "65 min", "blood pressure", "mmHg", "respirations", "20 min", "oxygen saturation", "97", "exam", "pale", "diaphoretic", "pupils", "contracted", "Diffuse wheezes", "noted", "lung fields", "best treatment", "condition"]}
{"question": "A 3-year-old male is brought in to his pediatrician by his mother because she is concerned that he is not growing appropriately. Physical examination is notable for frontal bossing and shortened upper and lower extremities. His axial skeleton appears normal. He is at the 7th percentile for height and 95th percentile for head circumference. He demonstrates normal intelligence and is able to speak in three-word sentences. He first sat up without support at twelve months and started walking at 24 months. Genetic analysis reveals an activating mutation in a growth factor receptor. Which of the following physiologic processes is most likely disrupted in this patient’s condition?", "answer": "Endochondral ossification", "options": {"A": "Intramembranous ossification", "B": "Osteoblast maturation", "C": "Endochondral ossification", "D": "Production of type I collagen"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old male", "brought", "pediatrician", "mother", "concerned", "not", "Physical examination", "notable", "frontal bossing", "shortened upper", "lower extremities", "axial skeleton appears normal", "percentile", "height", "95th percentile", "head circumference", "demonstrates normal intelligence", "able", "speak", "three word sentences", "first sat up", "support", "twelve months", "started walking", "months", "Genetic analysis reveals", "activating mutation", "growth factor receptor", "following physiologic processes", "most likely disrupted", "patients condition"]}
{"question": "A 59-year-old woman comes to the physician 2 weeks after noticing a lump in her left breast. Examination of the left breast shows a firm, nontender mass close to the nipple. Mammography shows an irregular calcified mass. A core needle biopsy shows invasive ductal carcinoma. Genetic analysis of this patient's cancer cells is most likely to show overexpression of which of the following genes?", "answer": "HER2", "options": {"A": "HER2", "B": "BCR-ABL", "C": "BRCA-2", "D": "BCL-2"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old woman", "physician 2 weeks", "lump in", "left breast", "Examination", "shows", "firm", "nontender mass close", "nipple", "Mammography shows", "irregular calcified mass", "core needle biopsy shows invasive ductal carcinoma", "Genetic analysis", "patient's cancer cells", "most likely to show overexpression", "following genes"]}
{"question": "A 45-year-old man comes to his primary-care doctor with his wife for a 4-week history of constipation. The patient reports that his bowel habits have changed from every day to every 3 or 4 days. He also now has to strain to pass stool. On further questioning, his wife has also noticed that he has seemed fatigued, with little interest in going on their usual afternoon walks. Medical history is notable for hypertension and hyperlipidemia, both managed medically. He was last seen for follow-up of these conditions 1 month ago. Physical examination is unremarkable. Which of the following is the cellular target of the medicine that is most likely responsible for this patient's symptoms?", "answer": "Na+/Cl- cotransporter in the membranes of epithelial cells in the distal convoluted tubule", "options": {"A": "Angiotensin-II receptors in the membranes of vascular smooth muscle cells", "B": "Angiotensin-converting enzyme", "C": "Na+/Cl- cotransporter in the membranes of epithelial cells in the distal convoluted tubule", "D": "Na+/K+/2Cl- transporters in the membranes of epithelial cells in the ascending loop of Henle"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "primary-care doctor", "wife", "week history", "constipation", "patient reports", "bowel habits", "changed", "day", "3", "4 days", "now", "to strain to pass stool", "further questioning", "wife", "fatigued", "little interest in", "usual afternoon walks", "Medical history", "notable", "hypertension", "hyperlipidemia", "managed", "last seen", "follow-up", "conditions 1 month", "Physical examination", "unremarkable", "following", "cellular target", "medicine", "most likely responsible", "patient's symptoms"]}
{"question": "A 23-year-old man presents to the office for a circular, itchy rash over the abdomen that has been slowly getting worse for the past 2 weeks. The patient has a medical history of chronic dermatitis and chronic sinusitis for which he has prescriptions of topical hydrocortisone and fexofenadine. He smokes one-half pack of cigarettes every day. His vital signs include: blood pressure 128/76 mm Hg, heart rate 78/min, and respirations 12/min. On physical examination, the patient appears tired but oriented. Examination of the skin reveals a 2 x 2 cm round and erythematous, annular plaque on the abdomen 3 cm to the left of the umbilicus. There are no vesicles, pustules, or papules. Auscultation of the heart reveals a 1/6 systolic murmur. Breath sounds are mildly coarse at the bases. A KOH preparation from the skin scraping confirms the presence of hyphae. Which of the following is the next best step in the management of this patient?", "answer": "Itraconazole", "options": {"A": "Itraconazole", "B": "Griseofulvin", "C": "Topical clindamycin", "D": "Doxycycline"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old man presents", "office", "circular", "itchy rash", "abdomen", "slowly getting worse", "past 2 weeks", "patient", "medical history of chronic dermatitis", "chronic sinusitis", "prescriptions", "topical hydrocortisone", "fexofenadine", "smokes one half pack", "cigarettes", "day", "vital signs include", "blood pressure", "76 mm Hg", "heart rate", "min", "respirations", "min", "physical examination", "patient appears tired", "oriented", "Examination of", "skin reveals", "2", "2", "round", "erythematous", "annular", "abdomen", "left", "umbilicus", "vesicles", "pustules", "papules", "Auscultation of", "heart reveals", "systolic murmur", "Breath sounds", "mildly coarse", "bases", "KOH preparation", "skin scraping confirms", "presence", "hyphae", "following", "next best step", "management", "patient"]}
{"question": "A 12-year-old boy is brought to the emergency department for the evaluation of persistent bleeding from his nose over the past hour. The bleeding started spontaneously. He has no history of a similar episode. He takes no medications. There is no history of abnormal bleeding in the family. His vital signs are within normal limits. On examination, he is pressing a gauze against his left nostril while hyperextending his head. The gauze is stained with blood and upon withdrawal of the gauze blood slowly drips out of his left nostrils. There is no bleeding from the right nostril. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate initial therapy?", "answer": "Squeezing the nostrils manually for 10 minutes with the head elevated", "options": {"A": "Anterior packing and topical antibiotics", "B": "Oxymetazoline nasal spray", "C": "Placement of an epinephrine gauze in the left nostril", "D": "Squeezing the nostrils manually for 10 minutes with the head elevated"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "evaluation", "persistent bleeding", "nose", "past hour", "bleeding started", "history of", "similar episode", "takes", "medications", "history", "abnormal bleeding", "family", "vital signs", "normal limits", "examination", "gauze", "left nostril", "head", "gauze", "stained", "blood", "withdrawal", "gauze blood slowly drips out", "left nostrils", "bleeding", "right nostril", "physical examination shows", "abnormalities", "following", "most appropriate initial therapy"]}
{"question": "A 40-year-old female presents to your office complaining of a tender neck and general lethargy. Upon further questioning, she reports decreased appetite, fatigue, constipation, and jaw pain. Her pulse is 60 bpm and her blood pressure is 130/110 mm Hg. Biopsy of her thyroid reveals granulomatous inflammation and multinucleate giant cells surrounding fragmented colloid. Which of the following likely precipitated the patient’s condition:", "answer": "Infection", "options": {"A": "Iodine deficiency", "B": "Thryoglossal duct cyst", "C": "Infection", "D": "Chronic renal disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old female presents", "office", "tender", "general lethargy", "further questioning", "reports decreased appetite", "fatigue", "constipation", "jaw pain", "pulse", "60", "blood pressure", "mm Hg", "Biopsy of", "thyroid reveals granulomatous inflammation", "multinucleate giant cells surrounding fragmented colloid", "following likely precipitated", "patients condition"]}
{"question": "A 24-year-old man is brought to the emergency room by the police after a fall. The patient smells of alcohol and is slurring his words. You find out that he has recently been fired from his job as a salesperson for months of tardiness and poor performance. The police tell you that his girlfriend, who was there at the time of the fall, mentioned that the patient has been struggling with alcohol for at least a year. Upon physical examination, the patient becomes agitated and starts yelling. He accuses his ex-boss of being a cocaine addict and says he couldn’t keep up sales percentages compared to someone using cocaine. Which of the following psychiatric defense mechanisms is the patient demonstrating?", "answer": "Projection", "options": {"A": "Denial", "B": "Displacement", "C": "Projection", "D": "Regression"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency room", "police", "fall", "patient smells", "alcohol", "slurring", "words", "find out", "recently", "fired", "job", "salesperson", "months", "tardiness", "poor performance", "police", "girlfriend", "time", "fall", "patient", "alcohol", "year", "physical examination", "patient", "agitated", "starts", "ex boss", "cocaine addict", "keep", "sales percentages compared", "using cocaine", "following psychiatric defense mechanisms", "patient"]}
{"question": "A 65-year-old woman presents to a physician with painful ankles for 2 days. Her symptoms began 1 week ago with a severe fever (40℃ (104℉)) for 3 days. When the fever subsided, she developed a maculopapular rash over the trunk and extremities with painful wrists and fingers. She also reports abdominal pain, nausea, vomiting, and headaches. Last week she returned from a trip to Africa where she spent several weeks, mostly in rural areas. Her temperature is 37.5℃ (99.5℉); pulse is 75/min; respiratory rate is 13/min, and blood pressure is 115/70 mm Hg. A maculopapular rash is observed over the trunk and limbs. Both ankles are swollen and painful to active and passive motion. The abdomen is soft without organomegaly. Laboratory studies show the following:\nLaboratory test\nHemoglobin 11.4 g/d\nMean corpuscular volume 90 µm3\nLeukocyte count 4,500/mm3\nSegmented neutrophils 70%\nLymphocytes 15%\nPlatelet count 250,000/mm3\nRing-form trophozoites are absent on the peripheral blood smear. Which of the following organisms is the most likely cause of this patient’s illness?", "answer": "Chikungunya virus", "options": {"A": "Babesia babesia", "B": "Chikungunya virus", "C": "Dengue virus", "D": "Leishmania major"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old woman presents", "physician", "painful ankles", "2 days", "symptoms began 1 week", "severe fever", "40", "3 days", "fever", "maculopapular rash", "trunk", "extremities", "painful", "fingers", "reports abdominal pain", "nausea", "vomiting", "headaches", "Last week", "returned", "trip", "Africa", "spent several weeks", "mostly", "rural areas", "temperature", "99.5", "pulse", "75 min", "respiratory rate", "min", "blood pressure", "70 mm Hg", "maculopapular rash", "observed", "trunk", "limbs", "ankles", "swollen", "painful", "active", "passive motion", "abdomen", "soft", "organomegaly", "Laboratory studies show", "following", "Laboratory", "g Mean corpuscular volume 90 m3 Leukocyte count", "500 mm3 Segmented neutrophils", "Platelet", "Ring-form trophozoites", "absent", "peripheral blood smear", "following organisms", "most likely cause", "patients illness"]}
{"question": "A 61-year-old man complaining of unexplained bleeding by from the mouth is escorted to the emergency department by corrections officers. Upon examination patient states he feels nauseated as he begins to retch violently and vomit bright red blood. His past medical history is remarkable for cirrhosis secondary to alcohol abuse and untreated hepatitis C. His current blood pressure is 90/50 mm Hg, heart rate is 128/min, and oxygen saturation in room air is 88%. On further questioning, he states that he is scared to die and wants everything done to save his life. IV fluids are initiated and packed RBCs are ordered. You begin to review his labs and notice and he has elevated beta-hydroxybutyrate, ammonia, and lactate. What would be the appropriate response to the patient?", "answer": "Accept the patient's wishes and ensure he receives appropriate care.", "options": {"A": "Consult an ethics committee to determine whether to resuscitate the patient", "B": "Accept the patient's wishes and appoint and get a psych evaluation.", "C": "Accept the patient's wishes and ensure he receives appropriate care.", "D": "Obtain an emergency order from a judge to initiate resuscitation."}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["61 year old man", "unexplained bleeding", "mouth", "escorted", "emergency department", "corrections officers", "examination patient states", "feels nauseated", "begins to retch", "vomit bright red blood", "past medical history", "cirrhosis secondary to alcohol abuse", "untreated hepatitis C", "current blood pressure", "90 50 mm Hg", "heart rate", "min", "oxygen saturation", "room air", "88", "further questioning", "states", "scared to die", "to save", "life", "IV fluids", "initiated", "packed RBCs", "ordered", "begin to review", "labs", "elevated beta-hydroxybutyrate", "ammonia", "lactate", "appropriate response", "patient"]}
{"question": "Three days after undergoing a laparoscopic Whipple's procedure, a 43-year-old woman has swelling of her right leg. She does not have pain. She has nausea but has not vomited. She was diagnosed with pancreatic cancer 1 month ago. She has been using an incentive spirometer every 6 hours since recovering from her surgery. Prior to admission, her only medications were a multivitamin and an herbal weight-loss preparation. She appears uncomfortable. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure is 118/78 mm Hg. Examination shows mild swelling of the right thigh to the ankle; there is no erythema or pitting edema. Homan's sign is negative. The abdomen is soft and shows diffuse tenderness to palpation. There are five abdominal laparoscopic incisions with no erythema or discharge. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Compression ultrasonography", "options": {"A": "CT pulmonary angiography", "B": "Compression ultrasonography", "C": "D-dimer level", "D": "2 sets of blood cultures\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Three days", "laparoscopic", "procedure", "year old woman", "swelling of", "right leg", "not", "pain", "nausea", "not vomited", "diagnosed", "pancreatic cancer", "month", "using", "incentive spirometer", "6 hours", "recovering from", "surgery", "admission", "only medications", "multivitamin", "herbal weight-loss preparation", "appears", "temperature", "100 4F", "pulse", "90 min", "blood pressure", "mm Hg", "Examination shows mild swelling", "right", "ankle", "erythema", "pitting edema", "Homan's sign", "negative", "abdomen", "soft", "shows diffuse tenderness", "palpation", "five abdominal laparoscopic incisions", "erythema", "discharge", "lungs", "clear", "auscultation", "examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 36-year-old man presents to a physician after having a transient loss of consciousness while resting after dinner the previous night. His symptoms only lasted for a few seconds and resolved spontaneously. This is the third time he experienced such an episode. He says that he recently started having nightmares. His father died of sudden cardiac death at the age of 45 years without a history of hypertension or any chronic cardiac disorder. A complete physical examination was normal. A 12-lead electrocardiogram showed ST-segment elevations in V1, V2, and V3, and the presence of incomplete right bundle branch block (RBBB). After a complete diagnostic evaluation, Brugada syndrome was diagnosed. He has prescribed a class I anti-arrhythmic drug, which is a sodium channel blocker that slows phase 0 depolarization in ventricular muscle fibers. The drug also blocks potassium channels and prolongs action potential duration, but it does not shorten phase 3 repolarization. The drug also has mild anticholinergic and alpha-blocking activity. If taken in high doses, which of the following are the most likely side effects of the drug?", "answer": "Headache and tinnitus", "options": {"A": "Headache and tinnitus", "B": "Pulmonary fibrosis and corneal deposits", "C": "Pedal edema and flushing", "D": "Hypothyroidism and phototoxicity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["36 year old man presents", "physician", "transient loss of consciousness", "resting", "dinner", "previous night", "symptoms only lasted", "seconds", "resolved", "third time", "experienced", "episode", "recently started", "nightmares", "father died", "sudden cardiac death", "age", "years", "history of hypertension", "chronic cardiac", "complete physical examination", "normal", "12-lead electrocardiogram showed ST-segment elevations", "V1", "V2", "V3", "presence", "incomplete right bundle branch block", "complete diagnostic evaluation", "Brugada syndrome", "diagnosed", "prescribed", "class I anti-arrhythmic drug", "sodium channel blocker", "slows phase 0 depolarization", "ventricular muscle fibers", "drug", "blocks potassium channels", "action potential duration", "not shorten phase 3", "drug", "mild anticholinergic", "alpha blocking activity", "taken", "high doses", "following", "most likely side effects of", "drug"]}
{"question": "A 52-year-old man is brought to the emergency department for recurrent vomiting that began 5 hours ago. He describes the vomitus as bloody and containing black specks. He drinks 10–12 beers daily and has not seen a physician in 15 years. He appears pale. His temperature is 36.7°C (98.1°F), pulse is 122/min, and blood pressure is 85/59 mm Hg. Physical examination shows decreased radial pulses, delayed capillary refill, multiple spider angiomata, and a distended abdomen. He is oriented to person but not to place or time. Which of the following is most likely decreased in this patient in response to his current condition compared to a healthy adult?", "answer": "Carotid baroreceptor firing activity", "options": {"A": "Systemic vascular resistance", "B": "Fractional tissue oxygen extraction", "C": "Carotid baroreceptor firing activity", "D": "Cardiac inotropy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "recurrent vomiting", "began 5 hours", "vomitus", "bloody", "containing black", "drinks", "beers daily", "not seen", "physician", "years", "appears pale", "temperature", "36", "98", "pulse", "min", "blood pressure", "85 59 mm Hg", "Physical examination shows decreased radial pulses", "delayed capillary refill", "multiple spider angiomata", "distended abdomen", "oriented to person", "not to place", "time", "following", "most likely decreased", "patient", "response", "current condition compared", "healthy adult"]}
{"question": "A 69-year-old male with a longstanding history of hypertension and high cholesterol presents with abdominal pain and ‘bruising on his feet’. The patient states that his symptoms started about a week ago and have steadily worsened. He describes the abdominal pain as mild to moderate, dull, and deeply localized to the umbilical region. Past medical history is significant for 2 transient ischemic attacks 6 months prior, characterized by a sudden right-sided weakness and trouble speaking but recovered fully within 30 minutes. Current medications are sildenafil 100 mg orally as needed. Patient reports a 30-pack-year smoking history and heavy alcohol use on the weekends. Review of systems is significant for decreased appetite and feeling easily full. Vitals are temperature 37°C (98.6°F), blood pressure 155/89 mm Hg, pulse 89/min, respirations 16/min, and oxygen saturation 98% on room air. On physical examination, the patient is alert and cooperative. The cardiac exam is normal. Lungs are clear to auscultation. Carotid bruit present on the right. The abdomen is soft and nontender. Bowel sounds present. A pulsatile abdominal mass is felt in the lower umbilical region. Patient’s feet have the following appearance seen in the picture. Abdominal ultrasound reveals the presence of an abdominal aortic aneurysm (AAA). Contrast CT reveals a small, unruptured AAA (diameter 4.1 cm). High flow supplemental oxygen and fluid resuscitation are initiated. Morphine sulfate and metoprolol are administered. Which of the following is the best course of treatment for this patient?\n ", "answer": "Emergency open surgical repair", "options": {"A": "Discharge with clinical surveillance and ultrasound every 6 months", "B": "Elective endovascular repair", "C": "Elective open surgical repair", "D": "Emergency open surgical repair"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["69 year old male", "history of hypertension", "high cholesterol presents", "abdominal pain", "bruising", "feet", "patient states", "symptoms started", "week", "worsened", "abdominal", "mild to moderate", "dull", "deeply localized", "umbilical region", "Past medical history", "significant", "transient ischemic attacks", "months prior", "characterized", "sudden right-sided weakness", "speaking", "recovered", "30 minutes", "Current medications", "sildenafil 100 mg orally", "needed", "Patient reports", "30 pack-year smoking history", "heavy alcohol use", "weekends", "Review of systems", "significant", "decreased appetite", "feeling easily full", "temperature", "98", "blood pressure", "mm Hg", "pulse", "min", "respirations", "min", "oxygen saturation 98", "room air", "physical examination", "patient", "alert", "cooperative", "cardiac exam", "normal", "Lungs", "clear", "auscultation", "Carotid bruit present", "right", "abdomen", "soft", "nontender", "Bowel sounds present", "pulsatile abdominal mass", "felt", "lower umbilical region", "Patients feet", "following appearance seen", "picture", "Abdominal ultrasound reveals", "presence of", "abdominal aortic aneurysm", "Contrast CT reveals", "small", "diameter", "High flow supplemental oxygen", "fluid resuscitation", "initiated", "Morphine sulfate", "metoprolol", "administered", "following", "best course", "treatment", "patient"]}
{"question": "A 38-year-old woman undergoes a partial thyroidectomy for an enlarged thyroid gland compressing the trachea. During surgery, a young surgeon ligates the inferior thyroid arteries as close to the poles as possible to prevent intraoperative hemorrhage. 2 weeks later, the patient presents to the outpatient clinic with hoarseness. What could be the most likely cause of her hoarseness?", "answer": "Recurrent laryngeal nerve injury", "options": {"A": "Internal laryngeal nerve injury", "B": "Recurrent laryngeal nerve injury", "C": "External laryngeal nerve injury", "D": "Laryngeal edema"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "partial thyroidectomy", "enlarged thyroid gland compressing", "trachea", "surgery", "young surgeon", "inferior thyroid arteries", "close", "poles", "possible to prevent intraoperative hemorrhage", "weeks later", "patient presents", "outpatient clinic", "hoarseness", "most likely cause", "hoarseness"]}
{"question": "A 17-year-old man presents to his family physician for an evaluation about the size of his penis. He feels increasingly anxious during physical education (PE) class as he has noticed that the size of his penis is significantly smaller when compared to his peers. Based on the physical examination, he is Tanner stage 1. The weight and height are 60 kg (132 lb) and 175 cm (5 ft 9 in), respectively. The cardiopulmonary examination is normal; however, the patient has difficulty identifying coffee grounds by smell. Which of the following explains the pathophysiology underlying this patient’s disorder?", "answer": "Isolated gonadotropin-releasing hormone (GnRH) deficiency", "options": {"A": "Expansion of a CTG trinucleotide repeat", "B": "Isolated gonadotropin-releasing hormone (GnRH) deficiency", "C": "Sex-specific epigenetic imprinting", "D": "Non-disjunction of sex chromosomes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "family physician", "evaluation", "size of", "penis", "feels", "anxious", "physical", "class", "size of", "penis", "smaller", "compared", "peers", "Based", "physical examination", "Tanner", "weight", "height", "60 kg", "5 ft 9", "cardiopulmonary examination", "normal", "patient", "difficulty", "coffee", "smell", "following", "pathophysiology", "patients disorder"]}
{"question": "A 63-year-old man is aiming to improve his health by eating a well balanced diet, walking daily, and quitting smoking following a 45-year smoking history. While on his daily walks he notices a strong cramping pain in his calves that consistently appears after a mile of walking. He sees his physician and a diagnosis of peripheral artery disease with intermittent claudication is made. To improve his symptoms, cilostazol is prescribed. What is the mechanism of action of this medication?", "answer": "Phosphodiesterase inhibitor", "options": {"A": "Irreversible cyclooxygenase inhibitor", "B": "Thromboxane synthase inhibitor", "C": "Adenosine diphosphate receptor inhibitor", "D": "Phosphodiesterase inhibitor"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["63 year old man", "aiming to", "health", "eating", "well balanced diet", "walking daily", "quitting smoking following", "year smoking history", "daily walks", "strong cramping pain in", "calves", "appears", "mile", "walking", "sees", "physician", "diagnosis of peripheral artery disease", "intermittent claudication", "made", "To", "symptoms", "cilostazol", "prescribed", "mechanism of action", "medication"]}
{"question": "A 37-year-old man comes to the emergency department with the chief complaint of a high fever for several days. In addition to the fever, he has had malaise, chest pain, and a dry cough. He recently went on vacation to South America but has returned to his job delivering packages. He has several friends who recently had influenza. Hi temperature is 102.8°F (39.3 °C), blood pressure is 137/80 mmHg, pulse is 104/min, respirations are 19/min, and oxygen saturation is 98%. Chest exam reveals a deep noise found bilaterally in the lung bases. Chest radiograph reveals a wider area of opacity near the heart and bilateral lung infiltrates. Which of the following is characteristic of the most likely organism responsible for this patient's symptoms?", "answer": "D-glutamate capsule", "options": {"A": "Cultured on charcoal and yeast", "B": "D-glutamate capsule", "C": "Found in desert sand", "D": "Polyribosyl-ribitol-phosphate capsule"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "chief complaint", "high fever", "several days", "fever", "malaise", "chest pain", "dry cough", "recently", "vacation", "South America", "returned", "job delivering packages", "several friends", "recently", "influenza", "Hi temperature", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "Chest exam reveals", "deep noise found", "lung bases", "Chest radiograph reveals", "wider area", "opacity", "heart", "bilateral lung infiltrates", "following", "characteristic", "likely organism responsible", "patient's symptoms"]}
{"question": "A 34-year-old man presents to the emergency department complaining of headache, fever, chills, cough, shortness of breath, and chest pain for the past 4 days. He smokes 2 packs per day and drinks 2–3 beers every day. He denies any previous medical problems except for seasonal allergies for which he takes diphenhydramine on occasions. At the hospital, the vital signs include: temperature 40.0°C (104.0°F), blood pressure 140/80 mm Hg, heart rate 98/min, and respiratory rate 28/min. On physical exam, he is thin and poorly kept. His clothes appear dirty. Small scars are visible in the decubitus region of both arms. The lung sounds are equal with bilateral crackles, and heart auscultation reveals a systolic murmur that radiates to the left axilla. Petechiae are seen on the hard palate and palms of his hands. A chest X-ray and blood cultures are ordered. What is the most likely organism causing his symptoms?", "answer": "Staphylococcus aureus", "options": {"A": "Streptococci viridans", "B": "Staphylococcus aureus", "C": "Aspergillus fumigatus", "D": "Staphylococcus epidermidis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "headache", "fever", "chills", "cough", "shortness of breath", "chest pain", "past 4 days", "smokes 2 packs per day", "drinks 23 beers", "day", "denies", "previous medical problems", "seasonal allergies", "takes diphenhydramine", "occasions", "hospital", "vital signs include", "temperature 40", "blood pressure", "80 mm Hg", "heart rate 98 min", "respiratory rate", "min", "physical exam", "thin", "poorly kept", "clothes appear dirty", "Small scars", "visible", "decubitus region of", "arms", "lung sounds", "equal", "bilateral crackles", "heart auscultation reveals", "systolic murmur", "radiates", "left axilla", "Petechiae", "seen", "hard palate", "palms of", "hands", "chest X-ray", "blood cultures", "ordered", "most likely organism causing", "symptoms"]}
{"question": "A 42-year-old man presents to a neurologist for evaluation of severe headache. He started experiencing episodic headaches and palpitations 3 months ago; however, he thought that these symptoms were simply related to the stress of moving and starting a new job. He has continued to experience these intermittent headaches and has also noticed that he sweats profusely during these episodes. On presentation his temperature is 99.1°F (37.3°C), blood pressure is 163/112 mmHg, pulse is 112/min, and respirations are 15/min. Physical exam reveals pallor and perspiration but is otherwise unremarkable. The most likely cause of this patient's symptoms is produced by cells located in which region of the histology slide shown in figure A?", "answer": "E", "options": {"A": "A", "B": "B", "C": "C", "D": "E"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "neurologist", "evaluation", "severe headache", "started experiencing episodic headaches", "palpitations", "months", "thought", "symptoms", "related", "stress", "moving", "starting", "new job", "continued to experience", "intermittent headaches", "sweats", "episodes", "presentation", "temperature", "99", "3C", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "Physical exam reveals pallor", "perspiration", "unremarkable", "most likely cause", "patient's symptoms", "cells", "region", "histology slide shown"]}
{"question": "A 62-year-old woman presents to the emergency department for vision changes. About 90 minutes ago she was on the couch watching television with her husband when she suddenly noticed that she couldn't see the screen normally. She also felt a little dizzy. She has never had anything like this happen before. Her general physical exam is unremarkable. Her neurologic exam is notable for loss of vision in the right visual field of both eyes with macular sparing, though extraocular movements are intact. A computed tomography (CT) scan of the head shows no acute intracranial process. Angiography of the brain will most likely show a lesion in which of the following vessels?", "answer": "Posterior cerebral artery", "options": {"A": "Internal carotid artery", "B": "Anterior cerebral artery", "C": "Posterior cerebral artery", "D": "Basilar artery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["62 year old woman presents", "emergency department", "vision changes", "90 minutes", "watching television", "husband", "see", "screen", "felt", "little dizzy", "never", "happen before", "general", "unremarkable", "neurologic exam", "notable", "loss of vision", "right visual field", "eyes", "macular sparing", "extraocular movements", "intact", "computed tomography", "scan of", "head shows", "acute intracranial process", "Angiography", "brain", "most likely show", "lesion", "following vessels"]}
{"question": "A three-day-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her son's skin appears yellow. She reports that the child cries several times per day, but sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding the infant but feels the latch has been poor and is unsure how much milk he has been consuming but feels it is not enough. A lactation consult was called for the patient and it was noted that despite proper instruction the observed latch was still poor. When asked the mother stated that the baby is currently making stools 2 times per day. Which of the following is the most likely etiology of the patient's presentation?", "answer": "Breastfeeding jaundice", "options": {"A": "Breast milk jaundice", "B": "Breastfeeding jaundice", "C": "Sepsis", "D": "Physiologic hyperbilirubinemia"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["three day old", "full-term infant born", "uncomplicated vaginal", "brought", "pediatrician", "mother", "notes", "son's skin appears yellow", "reports", "child cries", "times per day", "sleeps", "8 hours", "night", "breastfeeding", "infant", "feels", "latch", "poor", "unsure", "milk", "feels", "not", "lactation consult", "called", "patient", "noted", "instruction", "observed latch", "poor", "mother stated", "baby", "currently making stools", "times per day", "following", "most likely etiology", "patient's presentation"]}
{"question": "A 59-year-old man is brought to the emergency department with a history of black, tarry stools but denies vomiting of blood or abdominal pain. His family has noticed progressive confusion. History is significant for liver cirrhosis and alcoholism. His heart rate is 112/min, temperature is 37.1°C (98.7°F), and blood pressure is 110/70 mm Hg. On examination, he is jaundiced, lethargic, is oriented to person and place but not date, and has moderate ascites. Neurological examination reveals asterixis, and his stool is guaiac-positive. Liver function test are shown below:\nTotal albumin 2 g/dL\nProthrombin time 9 seconds\nTotal bilirubin 5 mg/dL\nAlanine aminotransferase (ALT) 100 U/L\nAspartate aminotransferase (AST) 220 U/L\nWhich of the following is a feature of this patient condition?", "answer": "It is a diagnosis of exclusion", "options": {"A": "Ammonia level is the best initial test to confirm the diagnosis", "B": "It is a diagnosis of exclusion", "C": "It only occurs in patients with cirrhosis", "D": "Electroencephalography (EEG) usually shows focal localising abnormality"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old man", "brought", "emergency department", "history", "black", "tarry stools", "denies vomiting of blood", "abdominal pain", "family", "progressive confusion", "History", "significant", "liver cirrhosis", "alcoholism", "heart rate", "min", "temperature", "98", "blood pressure", "70 mm Hg", "examination", "jaundiced", "lethargic", "oriented to person", "place", "not date", "moderate ascites", "Neurological examination reveals asterixis", "stool", "guaiac-positive", "Liver function test", "shown", "Total albumin", "g dL Prothrombin time 9", "bilirubin 5 mg dL Alanine aminotransferase", "ALT", "100 U/L Aspartate aminotransferase", "AST", "U/L", "following", "feature", "patient"]}
{"question": "A 20-year-old healthy man is running on a treadmill for the last 30 minutes. He is in good shape and exercises 3 times per week. He takes no medications and denies smoking cigarettes, drinking alcohol, and illicit drug use. Prior to starting his run, his heart rate was 70/min, and the blood pressure was 114/74 mm Hg. Immediately after stopping his run, the heart rate is 130/min, and the blood pressure is 145/75 mm Hg. Which of the following is most likely responsible for the change in his heart rate and blood pressure?", "answer": "Sympathetic nervous system activation", "options": {"A": "Baroreceptor reflex", "B": "Increased activation of the vagal nuclei", "C": "Sympathetic nervous system activation", "D": "Vasopressin release from the pituitary"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old healthy man", "running", "treadmill", "last 30 minutes", "good shape", "exercises 3 times per week", "takes", "medications", "denies smoking cigarettes", "drinking alcohol", "illicit drug use", "starting", "run", "heart rate", "70 min", "blood pressure", "74 mm Hg", "Immediately", "stopping", "run", "heart rate", "min", "blood pressure", "75 mm Hg", "following", "most likely responsible", "change", "heart rate", "blood pressure"]}
{"question": "A 14-year-old obese boy presents with severe right hip and knee pain. The patient says that he has been limping with mild pain for the past three weeks, but the pain acutely worsened today. He describes the pain as severe, non-radiating, sharp and aching in character, and localized to the right hip and knee joints. The patient denies recent illness, travel, trauma, or similar symptoms in the past. No significant past medical history and no current medications. The patient is not sexually active and denies any alcohol, smoking or drug use. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 110/70 mm Hg, pulse 72/min, respiratory rate 15/min, and oxygen saturation 99% on room air. Body mass index (BMI) is 32 kg/m2. On physical examination, the patient is alert and cooperative. The right leg is externally rotated, and there is a limited range of motion in the right hip. Strength is 4 out of 5 at the right hip joint and 5 out of 5 elsewhere. There is no tenderness to palpation. No joint erythema, edema or effusion present. Sensation is intact. Deep tendon reflexes are 2+ bilaterally. Laboratory tests are unremarkable. Plain radiographs of the right hip joint are significant for displacement of the right femoral head inferoposterior off the femoral neck. Which of the following is the most appropriate course of treatment for this patient?", "answer": "Surgical pinning of the right hip", "options": {"A": "Reassess in 3 months", "B": "Intra-articular corticosteroid injection of the right hip joint", "C": "Pavlik harness", "D": "Surgical pinning of the right hip"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old obese boy presents", "severe right hip", "knee pain", "patient", "limping", "mild pain", "past three weeks", "pain", "worsened today", "pain", "severe", "non radiating", "sharp", "aching", "character", "localized", "right hip", "knee joints", "patient denies recent illness", "travel", "trauma", "similar symptoms", "past", "significant past medical history", "current medications", "patient", "not sexually active", "denies", "alcohol", "smoking", "drug use", "vital signs include", "temperature", "98", "blood pressure", "70 mm Hg", "pulse 72 min", "respiratory rate", "min", "oxygen 99", "room air", "Body mass index", "kg/m2", "physical examination", "patient", "alert", "cooperative", "right leg", "externally rotated", "limited range of motion", "right hip", "Strength", "4 out of 5", "right hip joint", "5 out of 5", "tenderness", "palpation", "joint erythema", "edema", "effusion present", "Sensation", "intact", "Deep tendon reflexes", "2", "Laboratory tests", "unremarkable", "Plain radiographs of", "right hip joint", "significant", "displacement of", "right femoral head", "femoral neck", "following", "most appropriate course", "treatment", "patient"]}
{"question": "A 32-year-old man comes to the physician because of a progressive development of tender breast tissue over the past 18 months. He used to ride his bicycle for exercise 4 times a week but stopped after he had an accident and injured his left testicle 3 months ago. He has gained 5 kg (11 lb) during this period. For the last 10 years, he drinks one to two beers daily and sometimes more on weekends. He occasionally takes pantoprazole for heartburn. He is 171 cm (5 ft 7 in) tall and weighs 87 kg (192 lb); BMI is 30 kg/m2. Vital signs are within normal limits. Examination shows bilaterally symmetrical, mildly tender gynecomastia. A nontender 1.5-cm mass is palpated in the left testis; transillumination test is negative. The remainder of the examination shows no abnormalities. Which of the following is the most likely underlying cause of these findings?", "answer": "Leydig cell tumor", "options": {"A": "Leydig cell tumor", "B": "Obesity", "C": "Klinefelter syndrome", "D": "Trauma to testis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "progressive development", "tender breast tissue", "past", "months", "used to", "bicycle", "exercise", "times", "week", "stopped", "accident", "injured", "left testicle", "months", "gained 5 kg", "period", "last 10 years", "drinks one", "two beers daily", "sometimes", "weekends", "occasionally takes pantoprazole", "heartburn", "5 ft", "tall", "87 kg", "BMI", "30 kg/m2", "Vital signs", "normal limits", "Examination shows", "symmetrical", "mildly tender gynecomastia", "nontender", "mass", "palpated", "left testis", "transillumination test", "negative", "examination shows", "abnormalities", "following", "most likely underlying cause", "findings"]}
{"question": "A 58-year-old man comes to the physician because he is unable to achieve erections during sexual intercourse. He first noticed the problem 8 months ago, when he became sexually active with a new girlfriend. He states that his relationship with his girlfriend is good, but his inability to engage in sexual intercourse has been frustrating. He has hyperlipidemia and was diagnosed with major depressive disorder 3 years ago. He works as a lawyer and enjoys his job, but he has had a great deal of stress lately. He had not been sexually active for the previous 3 years, since the death of his wife. He does not smoke. He drinks 4–6 beers on weekends. Current medications include simvastatin and citalopram. His temperature is 37.5°C (99.5°F), pulse is 80/min, and blood pressure is 135/82 mm Hg. BMI is 30 kg/m2. Pedal pulses are difficult to palpate. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Nocturnal penile tumescence testing", "options": {"A": "Psychotherapy", "B": "Penile prosthesis insertion", "C": "Nocturnal penile tumescence testing", "D": "Switch citalopram to bupropion"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["58 year old man", "physician", "unable to", "erections", "sexual intercourse", "first", "problem", "months", "sexually active", "new girlfriend", "states", "relationship", "girlfriend", "good", "sexual intercourse", "hyperlipidemia", "diagnosed", "major depressive disorder", "years", "works", "lawyer", "job", "great", "stress", "not", "sexually active", "previous", "years", "death", "wife", "not smoke", "drinks", "beers", "weekends", "Current medications include simvastatin", "citalopram", "temperature", "99", "pulse", "80 min", "blood pressure", "mm Hg", "BMI", "30 kg/m2", "Pedal pulses", "difficult to palpate", "physical examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 5-year-old male presents to the pediatrician with a 10-day history of cough that is worse at night. The patient has a history of mild intermittent asthma and has been using his albuterol inhaler without relief. He has also been complaining of headache and sore throat, and his mother has noticed worsening rhinorrhea. The patient’s past medical history is otherwise unremarkable, and he has no known drug allergies. In the office, his temperature is 101.8°F (38.8°C), blood pressure is 88/65 mmHg, pulse is 132/min, and respirations are 16/min. The patient has purulent mucus draining from the nares, and his face is tender to palpation over the maxillary sinuses. His pharynx is erythematous with symmetric swelling of the tonsils. On lung exam, he has moderate bilateral expiratory wheezing.\n\nWhich of the following is the best next step in management?", "answer": "Amoxicillin-clavulanic acid", "options": {"A": "Amoxicillin", "B": "Amoxicillin-clavulanic acid", "C": "Clindamycin", "D": "Levofloxacin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old male presents", "pediatrician", "a 10 day history", "cough", "worse", "night", "patient", "history of mild intermittent asthma", "using", "albuterol inhaler", "relief", "headache", "sore throat", "mother", "worsening rhinorrhea", "patients past medical history", "unremarkable", "known drug allergies", "office", "temperature", "blood pressure", "88 65 mmHg", "pulse", "min", "respirations", "min", "patient", "purulent mucus draining", "nares", "face", "tender", "palpation", "maxillary sinuses", "pharynx", "erythematous", "symmetric swelling of", "tonsils", "lung exam", "moderate bilateral expiratory wheezing", "following", "best next step", "management"]}
{"question": "A 65-year-old man, known to have chronic obstructive lung disease for the last 3 years, presents to the emergency department with a cough, breathing difficulty, and increased expectoration for a day. There is no history of fever. His regular medications include inhaled salmeterol and inhaled fluticasone propionate. He was a chronic smoker but quit smoking 2 years ago. His temperature is 37.1°C (98.8°F), the pulse rate is 88/min, the blood pressure is 128/86 mm Hg, and the respirations are 30/min. On physical examination, the use of the accessory muscles of respiration is evident and the arterial saturation of oxygen is 87%. Auscultation of the chest reveals the presence of bilateral rhonchi with diminished breath sounds in both lungs. Which of the following medications, if administered for the next 2 weeks, is most likely to reduce the risk of subsequent exacerbations over the next 6 months?", "answer": "Oral prednisone", "options": {"A": "Oral prednisone", "B": "Supplemental oxygen", "C": "Montelukast", "D": "Nebulized N-acetylcysteine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old man", "known to", "chronic obstructive lung disease", "years", "presents", "emergency department", "cough", "breathing difficulty", "increased expectoration", "day", "history", "fever", "regular medications include inhaled salmeterol", "inhaled fluticasone propionate", "chronic smoker", "quit smoking 2 years", "temperature", "98", "pulse rate", "88 min", "blood pressure", "mm Hg", "respirations", "30/min", "physical examination", "use of", "accessory muscles", "respiration", "evident", "arterial saturation", "oxygen", "87", "Auscultation", "chest reveals", "presence", "bilateral rhonchi", "diminished breath sounds", "lungs", "following medications", "administered", "next 2 weeks", "most likely to", "risk", "subsequent exacerbations", "next", "months"]}
{"question": "A 22-year-old woman presents to the emergency department for abdominal pain. The patient has been trying to get pregnant and was successful recently, but now she is experiencing abdominal pain, contractions, and a bloody vaginal discharge. According to her last appointment with her primary care provider, she is 10 weeks pregnant. The patient has a past medical history of constipation, anxiety, and substance abuse. She is not currently taking any medications. Her temperature is 99.5°F (37.5°C), blood pressure is 107/58 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a bloody vaginal discharge and an open cervix. The patient is initially extremely grateful for the care she is receiving and thanks the doctor and the nursing staff for saving her baby. Upon hearing the news that she is having a spontaneous abortion, the patient becomes angry and aggressive and states that her physician and the medical staff are incompetent, evil, and she is going to sue all of them. The patient is left to grieve but upon entering the room again you notice that the patient has new lacerations over her wrists and that some of the medical equipment in the room is broken. Which of the following is the most likely diagnosis?", "answer": "Borderline personality disorder", "options": {"A": "Antisocial personality disorder", "B": "Borderline personality disorder", "C": "Normal grief response", "D": "Post-traumatic stress disorder"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "abdominal pain", "patient", "to", "pregnant", "successful recently", "now", "experiencing abdominal pain", "contractions", "bloody vaginal discharge", "According", "appointment", "primary care provider", "10 weeks pregnant", "patient", "past medical constipation", "anxiety", "substance abuse", "not currently taking", "medications", "temperature", "99", "blood pressure", "58 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "bloody vaginal discharge", "open cervix", "patient", "initially extremely", "care", "receiving", "thanks", "doctor", "nursing staff", "saving", "baby", "hearing", "news", "spontaneous abortion", "patient", "angry", "aggressive", "states", "physician", "medical staff", "incompetent", "patient", "left to", "entering", "room", "patient", "new lacerations", "wrists", "medical equipment", "room", "broken", "following", "most likely diagnosis"]}
{"question": "A 45-year-old female presents to the emergency department with gross hematuria and acute, colicky flank pain. She denies any previous episodes of hematuria. She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain. The patient’s blood pressure and temperature are normal, but she is found to have proteinuria. Physical examination is negative for palpable flank masses. Which of the following is the most likely diagnosis:", "answer": "Papillary necrosis", "options": {"A": "Diffuse cortical necrosis", "B": "Chronic pyelonephritis", "C": "Papillary necrosis", "D": "Acute Nephrolithiasis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old female presents", "emergency department", "gross hematuria", "acute", "colicky flank", "denies", "previous episodes of hematuria", "reports taking high doses", "acetaminophen", "aspirin", "weeks", "persistent upper back pain", "patients blood pressure", "temperature", "normal", "found to", "proteinuria", "Physical examination", "negative", "palpable flank masses", "following", "most likely diagnosis"]}
{"question": "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?", "answer": "Excess weight", "options": {"A": "Medication side effect", "B": "Excess weight", "C": "Infection", "D": "Occult malignancy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["40 year old man presents", "clinic", "complaints", "increased bilateral pain", "knees", "pain", "time", "now limits", "mobility", "states", "pain", "worse", "end", "day", "early morning stiffness", "20 minutes", "used to", "success", "over-the-counter NSAIDs", "longer help", "patient", "taking metformin", "past", "years", "severely obese", "BMI", "kg/m2", "states", "felt", "tired", "day", "often", "work", "longer feels refreshed", "wakes up", "morning", "examination", "tenderness", "palpation", "erythema", "crepitus", "felt", "complaints", "family history of rheumatoid arthritis", "mothers side", "following factors", "underlying cause", "patients pain", "rest", "complaints"]}
{"question": "A 40-year-old man comes to the physician because of shortness of breath, double vision, and fatigue for the past 4 weeks. He has no history of serious medical illness and takes no medications. Physical examination shows drooping of the eyelids bilaterally. He is unable to hold his arms up for longer than 3 minutes. A CT scan of the chest shows an anterior mediastinal mass with smooth contours. A photomicrograph of a specimen from the mass is shown. Which of the following immunologic processes normally occurs in the region indicated by the arrow?", "answer": "Negative selection", "options": {"A": "B-cell maturation", "B": "V(D)J recombination", "C": "Thymocyte formation", "D": "Negative selection"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["40 year old man", "physician", "of shortness", "breath", "double vision", "fatigue", "past 4 weeks", "history of serious medical illness", "takes", "medications", "Physical examination shows drooping", "eyelids", "unable to hold", "arms", "longer", "minutes", "CT scan of", "chest shows", "anterior mediastinal mass", "smooth contours", "photomicrograph", "specimen", "mass", "shown", "following immunologic processes", "occurs", "region indicated", "arrow"]}
{"question": "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?", "answer": "μ, κ, and ẟ receptor antagonist", "options": {"A": "μ, κ, and ẟ receptor antagonist", "B": "μ receptor agonist", "C": "к receptor agonist and μ receptor antagonist", "D": "μ receptor partial agonist and к receptor agonist"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "parents", "found", "room", "responsive", "slurring speech", "patients parents", "bottle", "oxycodone", "found", "missing", "pills", "physical examination", "patient appears drowsy", "lethargic", "responsive", "stimuli", "respiratory rate", "min", "shallow", "blood pressure", "90 mm Hg", "pulse", "60 min", "physical examination", "miosis", "present", "pupils appear pinpoint", "patient", "given", "drug to", "symptoms", "following", "mechanism of action", "drug", "most likely administered"]}
{"question": "A 27-year-old woman comes to the physician because of increasing shortness of breath and a non-productive cough for 2 months. She has been unable to perform her daily activities. She has had malaise and bilateral ankle pain during this period. She noticed her symptoms after returning from a vacation to Arizona. She is a research assistant at the university geology laboratory. She is originally from Nigeria and visits her family there twice a year; her last trip was 3 months ago. Her temperature is 37.8°C (100°F), pulse is 100/min, respirations are 24/min, and blood pressure is 112/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. There is no palpable cervical or axillary lymphadenopathy. The lungs are clear to auscultation. Her left eye is notable for ciliary injection and photophobia. The remainder of the examination shows no abnormalities. A complete blood count is within the reference range. An x-ray of the chest is shown. Which of the following is the most likely diagnosis?", "answer": "Sarcoidosis", "options": {"A": "Sarcoidosis", "B": "Pulmonary tuberculosis", "C": "Hodgkin's lymphoma", "D": "Histoplasmosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old woman", "physician", "of increasing shortness", "breath", "non-productive cough", "months", "unable to perform", "daily activities", "malaise", "bilateral ankle", "period", "symptoms", "returning", "vacation", "Arizona", "research assistant", "university geology laboratory", "Nigeria", "visits", "family", "twice", "year", "last trip", "3 months", "temperature", "pulse", "100 min", "respirations", "min", "blood pressure", "72 mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "palpable cervical", "axillary lymphadenopathy", "lungs", "clear", "auscultation", "left eye", "notable", "ciliary injection", "photophobia", "examination shows", "abnormalities", "complete blood count", "reference range", "x-ray of", "chest", "shown", "following", "most likely diagnosis"]}
{"question": "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?", "answer": "CN X", "options": {"A": "CN X", "B": "CN VII", "C": "CN IX", "D": "CN V"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["75 year old man presents", "physician", "year history", "dysphagia", "solids", "more recent complaints include dysphagia", "liquids", "well", "patient states", "difficulty initiating swallowing", "occasionally food", "stuck", "throat", "not", "pain", "swallowing", "minor unintentional weight loss", "patient", "history", "speech related pain", "nasal regurgitation", "family history", "unremarkable", "examination", "patient appears ill", "malnourished", "slightly pale", "not jaundiced", "cyanotic", "Physical examination", "unremarkable", "swallowing study reveals", "small", "posterior", "see image", "nerve", "most likely involved", "patients"]}
{"question": "A 48-year-old female presents with an enlargement of her anterior neck which made swallowing very difficult for 2 weeks now. She has had constipation for the past 6 weeks and overall fatigue. She also had heavy menstrual bleeding; and often feels extremely cold at home. On the other hand, she has well-controlled asthma and spring allergies. On examination, the thyroid is stony hard, tender and asymmetrically enlarged. There is also pain associated with swallowing. Laboratory studies show a serum T4 level of 4.4 μg/dL and a TSH level of 6.3 mU/L. A radionuclide thyroid scanning indicates that the nodule has low radioactive iodine uptake. Which of the following is the most likely pathology to be found in this patient?", "answer": "Reidel thyroiditis", "options": {"A": "Anaplastic carcinoma", "B": "Medullary carcinoma", "C": "Reidel thyroiditis", "D": "Silent thyroiditis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old female presents", "enlargement of", "anterior neck", "made swallowing very difficult", "2 weeks now", "constipation", "past", "weeks", "overall fatigue", "heavy menstrual bleeding", "often feels extremely cold", "home", "hand", "well-controlled asthma", "spring allergies", "examination", "thyroid", "stony hard", "tender", "enlarged", "pain associated with swallowing", "Laboratory studies show", "serum T4 level", "g/dL", "level", "3 mU/L", "radionuclide thyroid", "nodule", "low radioactive iodine uptake", "following", "most likely pathology to", "found", "patient"]}
{"question": "A researcher is testing an unknown compound, X, and seeing the effect it has on renal function. When she applies compound X to the cells, she finds that the urinary concentration of sodium and the pH decreases while the urinary potassium increases. Which of the following correctly states:\n1) the cells of the kidney this compound acts on and\n2) the identity of compound X?", "answer": "Principal cells; aldosterone", "options": {"A": "Distal convoluted tubule; atrial natriuretic peptide", "B": "Distal convoluted tubule; hydrochlorothiazide", "C": "Principal cells; aldosterone", "D": "Principal cells; spironolactone"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["researcher", "testing", "unknown compound", "seeing", "effect", "renal function", "applies compound", "cells", "finds", "urinary concentration", "sodium", "pH decreases", "urinary potassium increases", "following", "states", "1", "cells", "kidney", "compound acts", "2", "identity", "compound"]}
{"question": "A 5-year-old male is brought to the pediatrician with complaints of a painful mouth/gums, and vesicular lesions on the lips and buccal mucosa for the past 4 days. The patient has not been able to eat or drink due to the pain and has been irritable. The patient also reports muscle aches. His vital signs are as follows: T 39.1, HR 110, BP 90/62, RR 18, SpO2 99%. Physical examination is significant for vesicular lesions noted on the tongue, gingiva, and lips, with some vesicles having ruptured and ulcerated, as well as palpable cervical and submandibular lymphadenopathy. Which of the following is the most likely causative organism in this patient's presentation?", "answer": "HSV-1", "options": {"A": "CMV", "B": "HIV", "C": "HSV-1", "D": "HSV-2"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["5 year old male", "brought", "pediatrician", "complaints", "painful mouth/gums", "vesicular lesions", "lips", "buccal mucosa", "past 4 days", "patient", "not", "able to eat", "drink due to", "pain", "irritable", "patient", "reports muscle aches", "vital signs", "follows", "T", "BP 90 62", "RR", "99", "Physical examination", "significant", "vesicular lesions noted", "tongue", "gingiva", "lips", "vesicles", "ruptured", "ulcerated", "palpable cervical", "submandibular lymphadenopathy", "following", "most likely", "organism", "patient's presentation"]}
{"question": "A patient is unresponsive in the emergency department following a motor vehicle accident. The patient's written advance directive states that he does not wish to be resuscitated in the event of a cardiac arrest. The patient's wife arrives and demands that \"everything\" be done to keep him alive because she \"can't go on living without him.\" The patient's adult son is on his way to the hospital. If the patient arrests, which of the following should occur?", "answer": "Respect the patient's prior wishes and do not resuscitate", "options": {"A": "Respect the wife's wishes and resuscitate the patient", "B": "Respect the patient's prior wishes and do not resuscitate", "C": "Consult a judge for the final decision on whether or not to resuscitate", "D": "Consult the hospital ethics committee"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["patient", "unresponsive", "emergency department following", "motor vehicle accident", "patient", "ritten  dvance directive  tates ", "ot  ish  o ", "esuscitated ", "vent ", "ardiac arrest.", "atient'", "fe a", "mands t", " k ep h", "ive b", "on", "ing wi", "ient's ", "t son is ", "ital. If", "ent arr sts, wh", "owing sho", "r?"]}
{"question": "A 63-year-old man comes to the emergency department because of retrosternal chest pain. He describes it as 7 out of 10 in intensity. He has coronary artery disease, hypertension, and type 2 diabetes mellitus. His current medications are aspirin, simvastatin, metformin, and enalapril. He has smoked one pack of cigarettes daily for 33 years. On arrival, his pulse is 136/min and irregular, respirations are 20/min, and blood pressure is 85/55 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. An ECG is shown. Which of the following is the most appropriate next step in management?", "answer": "Synchronized cardioversion", "options": {"A": "Coronary angiogram", "B": "Intravenous esmolol", "C": "Intravenous amiodarone", "D": "Synchronized cardioversion"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["63 year old man", "emergency department", "retrosternal chest pain", "out", "10", "intensity", "coronary artery disease", "hypertension", "type 2 diabetes mellitus", "current medications", "aspirin", "simvastatin", "metformin", "enalapril", "smoked one pack", "cigarettes daily", "years", "arrival", "pulse", "min", "irregular", "respirations", "20 min", "blood pressure", "85 55 mm Hg", "lungs", "clear", "auscultation", "Cardiac shows", "abnormalities", "ECG", "shown", "following", "most appropriate next step", "management"]}
{"question": "A 14-year-old boy presents with right upper quadrant abdominal pain and is found on ultrasound to have a gallstone. Based on clinical suspicion, a CBC, a Coombs test, and a bilirubin panel are obtained to determine the etiology of the gallstone. These tests reveal a mild normocytic anemia with associated reticulocytosis as well as an increased RDW. In addition there is an indirect hyperbilirubinemia and the Coombs test results are negative. To confirm the diagnosis, an osmotic fragility test is performed which shows increased fragility in hypotonic solution. In this patient, what findings would most likely be anticipated if a blood smear were obtained?", "answer": "Spherocytes", "options": {"A": "Hypersegmented neutrophils", "B": "Sideroblasts", "C": "Spherocytes", "D": "Dacrocytes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "right upper quadrant abdominal pain", "found", "ultrasound to", "gallstone", "Based", "clinical suspicion", "CBC", "Coombs test", "bilirubin panel", "obtained to", "etiology", "gallstone", "tests reveal", "mild normocytic with associated reticulocytosis", "increased RDW", "addition", "indirect hyperbilirubinemia", "Coombs test results", "negative", "To confirm", "diagnosis", "osmotic fragility test", "performed", "shows increased fragility", "hypotonic solution", "patient", "findings", "most likely", "anticipated", "blood smear", "obtained"]}
{"question": "A 32-year-old man comes to the physician because of a 2-day history of a tingling sensation in his right forearm. He reports that his symptoms started after he lifted heavy weights at the gym. Physical examination shows loss of sensation on the lateral side of the right forearm. Sensation over the thumb is intact. Range of motion of the neck is normal. His symptoms do not worsen with axial compression or distraction of the neck. Further examination of this patient is most likely to show weakness of which of the following actions?", "answer": "Elbow flexion", "options": {"A": "Elbow flexion", "B": "Forearm pronation", "C": "Index finger flexion", "D": "Wrist extension"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "2-day history", "tingling sensation", "right forearm", "reports", "symptoms started", "lifted heavy weights", "Physical examination shows loss of sensation", "lateral side", "right forearm", "Sensation", "thumb", "intact", "Range of motion", "neck", "normal", "symptoms", "not worsen", "axial compression", "distraction of", "neck", "Further examination", "patient", "most likely to show weakness", "following actions"]}
{"question": "A 30-year-old woman presents to your office with decreased appetite, malaise, and fever. Serologic tests reveal positive Anti-HBsAg and Anti-HAV IgM antibodies. Which of the following is most likely responsible for this patient's presentation?", "answer": "Shellfish", "options": {"A": "Needlestick", "B": "Unprotected sex", "C": "Shellfish", "D": "Acetaminophen overdose"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old woman presents", "office", "decreased appetite", "malaise", "fever", "Serologic tests reveal positive", "HBsAg", "Anti-HAV IgM antibodies", "following", "most likely responsible", "patient's presentation"]}
{"question": "A 63-year-old patient presents to the emergency department because of severe left leg pain and tingling. His condition started suddenly 30 minutes ago. He has had hypertension for the past 10 years for which he takes bisoprolol. He does not smoke or drink alcohol. His temperature is 37.1°C (98.7°F), the blood pressure is 130/80 mm Hg, and the pulse is 100/min and irregular. On physical examination, the patient appears in severe pain and his left leg is pale and cool. The popliteal pulse is weaker on the left side compared to the right side. Which of the following is the most common cause of this patient's condition?", "answer": "Arterial emboli", "options": {"A": "Vasculitis", "B": "Hyperhomocysteinemia", "C": "Arterial emboli", "D": "Arterial trauma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["63 year old patient presents", "emergency department", "severe left leg pain", "tingling", "condition started", "30 minutes", "hypertension", "past 10 years", "takes bisoprolol", "not smoke", "drink alcohol", "temperature", "98", "blood pressure", "80 mm Hg", "pulse", "100 min", "irregular", "physical examination", "patient appears", "severe pain", "left leg", "pale", "cool", "popliteal pulse", "weaker", "left side compared", "right side", "following", "most common cause", "patient's condition"]}
{"question": "A 17-year-old girl is brought to the pediatrician by her father for evaluation. He is concerned that she has not undergone puberty yet, while all of her classmates at school have. The patient herself feels well overall, with no specific complaints. Examination shows vital signs of T 98.9, HR 71, and BP 137/92. The physician notes undeveloped breasts and normal external and internal female genitalia in Tanner I stage of development. Her body mass index is within normal limits, she is in the 40th percentile for height, and she is agreeable and pleasant during the interview. Which of the following additional findings is likely present in this patient?", "answer": "Hypokalemia", "options": {"A": "Aromatase enzyme deficiency", "B": "Hypokalemia", "C": "XY karyotype", "D": "Hypercortisolism"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "pediatrician", "father", "evaluation", "concerned", "not", "puberty", "classmates", "school", "patient", "feels well overall", "specific complaints", "Examination shows vital signs", "98", "71", "BP", "physician notes", "breasts", "normal external", "internal", "Tanner", "development", "body mass index", "normal limits", "percentile", "height", "pleasant", "interview", "following additional findings", "likely present", "patient"]}
{"question": "Current recommendations state that a single hemoglobin A1c value of greater than 6.5% is diagnostic of diabetes mellitus. If this 6.5% cut-off is to be increased to 7.0%, which of the following would be true?", "answer": "Increase in false negative test results", "options": {"A": "Increase in false negative test results", "B": "Increase in false positive test results", "C": "Decrease in true negative test results", "D": "Increase in true positive test results"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Current recommendations state", "a single hemoglobin A1c value", "greater", "6.5", "diagnostic", "diabetes mellitus", "6.5", "cut-off", "to", "increased", "7.0", "following", "true"]}
{"question": "Patients with the diagnosis of sickle cell anemia make a specific type of hemoglobin known as HgbS. This mutation results in the sickling of their red blood cells when exposed to inciting factors such as hypoxic conditions. Patients are often treated with hydroxyurea, which has which of the following direct effects on their hemoglobin physiology?", "answer": "Increases levels of fetal hemoglobin (HgbF)", "options": {"A": "Decreases oxygen carrying capacity of hemoglobin", "B": "Increases levels of fetal hemoglobin (HgbF)", "C": "Decreases levels of HgbS", "D": "Decreases levels of fetal hemoglobin (HgbF)"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Patients", "diagnosis", "sickle cell anemia make a specific type", "hemoglobin known", "HgbS", "mutation results", "sickling", "red blood cells", "exposed", "factors", "hypoxic conditions", "Patients", "often treated with hydroxyurea", "following direct effects", "hemoglobin physiology"]}
{"question": "A 40-year-old man presents to the emergency department with altered mental status. He has a history of cirrhosis of the liver secondary to alcoholism. He started becoming more confused a few days ago and it has been getting gradually worse. His temperature is 98.8°F (37.1°C), blood pressure is 134/90 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended abdomen that is non-tender. Neurological exam is notable for a confused patient and asterixis. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 3.3 mEq/L\nHCO3-: 22 mEq/L\nBUN: 20 mg/dL\nGlucose: 59 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the best next treatment for this patient?", "answer": "Potassium", "options": {"A": "Dextrose", "B": "Lactulose", "C": "Potassium", "D": "Rifaximin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old man presents", "emergency department", "altered mental status", "history of cirrhosis", "liver secondary to alcoholism", "started", "more confused", "few days", "getting", "worse", "temperature", "98", "blood pressure", "90 mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam reveals", "distended abdomen", "non-tender", "Neurological exam", "notable", "confused patient", "asterixis", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "3.3 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "59 mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL", "following", "best next treatment", "patient"]}
{"question": "A previously healthy 4-month-old girl is brought to the emergency department by her parents because she has not stopped crying for the past 5 hours. Her parents report that she has not eaten anything during this period and that they were unable to calm her down. She has not had any trauma. She was born at term via vaginal delivery and her delivery was uncomplicated. Her vital signs are within normal limits. Examination shows a reddened and swollen 2nd toe of the left foot. A photograph of the left foot is shown. Which of the following is the most likely diagnosis?", "answer": "Hair tourniquet syndrome", "options": {"A": "Raynaud phenomenon", "B": "Ingrown toe nail", "C": "Hair tourniquet syndrome", "D": "Herpetic whitlow"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["healthy", "month old girl", "brought", "emergency department", "parents", "not stopped crying", "past", "hours", "parents report", "not eaten", "period", "unable to calm", "not", "trauma", "born", "term", "vaginal delivery", "delivery", "uncomplicated", "vital signs", "normal limits", "Examination shows", "swollen 2nd toe", "left foot", "photograph", "left foot", "shown", "following", "most likely diagnosis"]}
{"question": "A 35-year-old woman presents to the physician because of episodes of difficulty swallowing for the past 3 months. She feels solid food getting stuck in her chest behind the sternum. She does not have any issues with liquids. She has no coughing or nasal regurgitation. She has no hoarseness or weight loss. She reports occasional heartburn that has lasted for about a year. Her past medical history is significant for asthma and eczema. She has no history of any serious illness and takes no medications. Her vital signs are within normal limits. Physical examination shows no abnormal findings. An endoscopic image of the esophagus is shown. Mucosal biopsy shows eosinophilic infiltration. Which of the following is the most appropriate pharmacotherapy at this time?", "answer": "Omeprazole", "options": {"A": "Budesonide", "B": "Fluconazole", "C": "Nitroglycerin", "D": "Omeprazole"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["35 year old woman presents", "physician", "of episodes", "difficulty swallowing", "past 3 months", "feels solid food getting", "chest", "sternum", "not", "issues", "liquids", "coughing", "nasal regurgitation", "hoarseness", "weight loss", "reports occasional heartburn", "lasted", "year", "past medical history", "significant", "asthma", "eczema", "history", "serious illness", "takes", "medications", "vital signs", "normal", "Physical examination shows", "abnormal findings", "endoscopic image of", "esophagus", "shown", "Mucosal biopsy shows eosinophilic infiltration", "following", "most appropriate pharmacotherapy", "time"]}
{"question": "A 2-year-old boy in respiratory distress is brought to the emergency department by his parents. They state that approximately one hour after putting their child to sleep, a \"hacking\" cough was heard from his bedroom. After entering his room the parents state their child appeared to be in distress, making a high pitched noise with every breath. Beyond a runny nose for the past few days, the child has been healthy. He has no toys in his bed or access to any other small objects. Physical exam demonstrates a 2-year-old child in respiratory distress.\n\nWhich of the following choices is the proper management for this patient?", "answer": "Dexamethasome, racemic epinephrine and observation for 4 hours; discharge if stridor remits", "options": {"A": "Humidified oxygen and dexamethasone; discharge if the patient improves", "B": "Dexamethasome, racemic epinephrine and observation for 4 hours; discharge if stridor remits", "C": "Broncoscopy to remove a foreign body in the upper airway then discharge", "D": "Empiric intravenous (IV) antibiotics, intubate and admission"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["2 year old boy", "respiratory distress", "brought", "emergency department", "parents", "state", "approximately one hour", "putting", "child to sleep", "hacking", "cough", "heard", "bedroom", "entering", "room", "parents state", "child appeared to", "distress", "making", "high pitched noise", "breath", "runny nose", "past", "days", "child", "healthy", "toys", "bed", "access", "small objects", "Physical exam demonstrates", "2 year old", "respiratory distress", "following choices", "management", "patient"]}
{"question": "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?", "answer": "Conversion of a protein from an a-helix to a ß-pleated form, which resists degradation.", "options": {"A": "Loss of dopaminergic neurons in the substantia nigra pars compacta.", "B": "Autoimmune inflammation and demyelination of the peripheral nervous system.", "C": "Conversion of a protein from an a-helix to a ß-pleated form, which resists degradation.", "D": "Frontotemporal atrophy and the accumulation of intracellular, aggregated tau protein."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old woman", "significant medical history begins to experience memory loss", "personality changes", "next", "months", "symptoms", "more severe", "experiences rapid mental deterioration", "starts to", "sudden", "jerking movements", "response", "gait disturbances", "coma", "eight months", "onset", "symptoms", "process likely caused", "woman's illness"]}
{"question": "A 38-year-old woman presents with eye dryness and a foreign body sensation in the eyes. On physical examination, the oral cavity shows mucosal ulceration and atrophy. Biopsy of the lower lip shows marked lymphocytic infiltration of the minor salivary glands. Which of the following is most likely seen in this patient?", "answer": "Anti-Sjögren's syndrome type B (SS-B) antibody", "options": {"A": "Anti-Sjögren's syndrome type B (SS-B) antibody", "B": "Anti-centromere antibody", "C": "Anti-Jo-1 antibody", "D": "Anti-Scl-70 antibodies"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "eye dryness", "foreign body sensation in", "eyes", "physical examination", "oral cavity shows mucosal ulceration", "atrophy", "Biopsy of", "lower lip shows marked lymphocytic infiltration", "minor salivary glands", "following", "most likely seen", "patient"]}
{"question": "A 62-year-old man with a history of chronic bronchitis comes to the physician because of a 1-month history of worsening shortness of breath and cough productive of thick sputum. He smoked one pack of cigarettes daily for 20 years but quit 5 years ago. Physical examination shows an increased anteroposterior chest diameter and coarse crackles in the lower lung fields bilaterally. Treatment with a drug that directly antagonizes the effects of vagal stimulation on the airways is begun. Which of the following drugs was most likely started?", "answer": "Tiotropium", "options": {"A": "Fluticasone", "B": "Montelukast", "C": "Tiotropium", "D": "Cromolyn"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old man", "history of chronic bronchitis", "physician", "of", "month history", "worsening shortness", "breath", "cough productive", "thick", "smoked one pack", "cigarettes daily", "20 years", "quit", "years", "Physical examination shows", "increased", "chest diameter", "coarse crackles", "lower lung fields", "Treatment", "drug", "directly", "effects", "vagal stimulation", "airways", "begun", "following drugs", "most likely started"]}
{"question": "A 14-year-old boy is brought to the physician for evaluation of his sense of smell. Two days ago, his mother found that he had left the gas on in the kitchen, and he was unable to smell the odor of the gas. As a child, he was consistently in the 40th percentile for height; now he is in the 15th percentile. He had bilateral orchidopexy for cryptorchidism as an infant. The patient is unable to identify several common odors when presented with them. Physical examination shows sparse axillary and pubic hair and Tanner stage 1 genitals. Which of the following is the most likely underlying cause of the patient's condition?", "answer": "Impaired migration of GnRH neurons", "options": {"A": "Compression of pituitary stalk", "B": "Hyperprolactinemia", "C": "Impaired migration of GnRH neurons", "D": "Decreased thyroxine production"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "evaluation of", "sense", "smell", "Two days", "mother found", "left", "gas", "kitchen", "unable to smell", "odor", "gas", "child", "percentile", "height", "now", "percentile", "bilateral", "cryptorchidism", "infant", "patient", "unable to", "several common odors", "presented", "Physical examination shows", "axillary", "pubic hair", "Tanner stage 1 genitals", "following", "most likely underlying cause", "patient's condition"]}
{"question": "A 26-year-old woman comes to the physician for a follow-up vaccination 1 week after being bitten by a rodent while camping. She received appropriate post-exposure prophylaxis in the emergency department and has already received 2 doses of the rabies vaccine. The same physician has been managing the post-exposure care regimen. After the physician administers the third dose of the rabies vaccine, the patient asks him if he would like to join her for a movie and dinner. The physician is interested in going on a date with her. Which of the following is the most appropriate reaction for the physician to have to the patient's invitation?", "answer": "Inform the patient that romantic relationships with current patients are unethical.", "options": {"A": "Inform the patient that romantic relationships with current patients are unethical.", "B": "Inform the patient that he will go on a date with her because her case is uncomplicated and does not require decision-making on his part.", "C": "Inform the patient that dating her will never be appropriate even once the physician-patient relationship has been terminated.", "D": "Inform the patient that he will go on a date with her, but that she will have to transfer her care to a different physician."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "follow-up vaccination 1 week", "bitten", "rodent", "camping", "received appropriate post-exposure prophylaxis", "emergency department", "received 2 doses of", "rabies vaccine", "same physician", "managing", "post exposure care regimen", "physician administers", "third dose of", "rabies vaccine", "patient", "to", "movie", "dinner", "physician", "interested in", "date", "following", "most appropriate reaction", "physician to", "patient's invitation"]}
{"question": "A 38-year-old nursing home worker presents to the clinic with complaints of fever, loss of appetite, fatigue, and productive cough for the past couple of months. His fever is low-grade and sputum is often blood-tinged. He has lost 6.8 kg (15.0 lb) during this period and complains of profound night sweats. A plain radiograph of the patient’s chest shows consolidation in the apical part of the right lung. Baseline investigations show the following:\nComplete blood count\nHemoglobin 11 g/dL\nWhite blood cells  \nTotal count 16,000/mm3\nDifferential count  \nNeutrophils 35%\nLymphocytes 54%\nEosinophils 11%\nErythrocyte sedimentation rate 84 mm\nThe physician suspects that the patient is suffering from a chronic lung infection. Which of the following statements best describes the type of lung inflammation in this patient?", "answer": "It consists of a largely circumscribed granuloma with epithelioid cells with Langhans cells.", "options": {"A": "There are small granulomas with few epithelioid cells along with fibrosis.", "B": "It has a granuloma with Anitchov cells around a core of fibrinoid collagen necrosis.", "C": "It consists of a largely circumscribed granuloma with epithelioid cells with Langhans cells.", "D": "This type of granulomatous inflammation is also seen in histoplasmosis."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old nursing presents", "clinic", "complaints", "fever", "loss of appetite", "fatigue", "productive cough", "past couple", "months", "fever", "low-grade", "sputum", "often blood-tinged", "lost", "kg", "0", "period", "profound night sweats", "plain radiograph of", "patients chest shows consolidation", "apical part of", "right lung", "Baseline investigations show", "following", "blood", "g/dL White blood cells", "Differential", "35", "54", "sedimentation", "84 mm", "physician suspects", "patient", "suffering", "chronic lung", "following statements best", "type", "lung", "patient"]}
{"question": "A 16-year-old boy presents to the emergency department with shortness of breath after prolonged exposure to cold air during a recent hike with his friends. He informs the physician that he is asthmatic, but does not use inhalers regularly because he does not like using medications. He is a non-smoker and occasionally drinks alcohol. On physical examination, the temperature is 37.0°C (98.6°F), the pulse is 120/min, the blood pressure is 114/76 mm Hg, and the respiratory rate is 32/min. Auscultation of the chest reveals bilateral wheezing. The physician asks the nurse to administer nebulized albuterol; however, the boy declines nebulized albuterol because of a history of palpitations that he experienced previously. The physician then prescribes nebulized ipratropium bromide, which results in significant clinical improvement. Which of the following second messenger systems is affected by the drug that improved the boy's symptoms?", "answer": "Phosphoinositol system", "options": {"A": "Cyclic guanosine monophosphate (cGMP) system", "B": "Arachidonic acid system", "C": "Phosphoinositol system", "D": "Tyrosine kinase system"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy presents", "emergency department", "shortness of breath", "prolonged exposure to cold air", "recent", "friends", "informs", "physician", "asthmatic", "not use inhalers", "not", "using medications", "non-smoker", "occasionally drinks alcohol", "physical examination", "temperature", "98", "pulse", "min", "blood pressure", "76 mm Hg", "respiratory rate", "min", "Auscultation", "chest reveals bilateral wheezing", "physician", "nurse", "administer nebulized albuterol", "boy", "nebulized albuterol", "of", "history", "palpitations", "experienced", "physician then", "nebulized ipratropium bromide", "results", "significant clinical improvement", "following second messenger systems", "affected", "drug", "improved", "boy's symptoms"]}
{"question": "A 2050-g (4.5-lb) female newborn and a 2850-g (6.3-lb) female newborn are delivered at 37 weeks' gestation to a 23-year-old, gravida 2, para 1 woman. The mother had no prenatal care. Examination of the smaller newborn shows a flattened nose and left-sided clubfoot. The hematocrit is 42% for the smaller newborn and 71% for the larger newborn. This pregnancy was most likely which of the following?", "answer": "Monochorionic-diamniotic monozygotic", "options": {"A": "Monochorionic-diamniotic monozygotic", "B": "Dichorionic-diamniotic dizygotic", "C": "Monochorionic-monoamniotic monozygotic", "D": "Conjoined twins"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["female newborn", "female newborn", "delivered", "weeks", "gestation", "23 year old", "gravida 2", "para 1 woman", "mother", "prenatal care", "Examination", "smaller newborn shows", "flattened nose", "left-sided clubfoot", "hematocrit", "smaller newborn", "71", "larger newborn", "pregnancy", "most likely", "following"]}
{"question": "A 55-year-old woman is found to have an abnormal mass on routine mammography. The mass is biopsied and cytology results are diagnostic for invasive ductal adenocarcinoma that is estrogen receptor positive. The patient is started on chemotherapy and ultimately has the mass resected. She is taking tamoxifen and has regular outpatient follow up appointments to monitor for any recurrence of cancer. The patient has a past medical history of asthma, obesity, and a uterine leimyoma which was definitively treated last year. Her last menstrual period was at the age of 47. The patient's vital signs and exam are unremarkable. Which of the following is a potential complication that could occur in this patient?", "answer": "Deep venous thrombosis", "options": {"A": "Deep venous thrombosis", "B": "Eruption of seborrheic keratoses", "C": "Increased bleeding", "D": "Osteoporosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old woman", "found to", "abnormal mass", "routine mammography", "mass", "biopsied", "cytology results", "diagnostic", "invasive ductal adenocarcinoma", "estrogen receptor positive", "patient", "started", "chemotherapy", "mass resected", "taking tamoxifen", "regular outpatient follow up appointments to monitor", "recurrence", "cancer", "patient", "past medical", "obesity", "uterine", "treated last year", "last menstrual period", "age", "patient's vital signs", "exam", "unremarkable", "following", "potential complication", "occur", "patient"]}
{"question": "A 24-year-old woman is brought to the physician because of agitation, confusion, and lethargy. She has also had progressive recurring headaches and visual impairment over the last month. Three days ago, she had a seizure but has not seen a physician. She is oriented only to person. Her temperature is 36.7°C (98.1°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Capillary refill time is more than 3 seconds. Her laboratory studies show:\nHemoglobin 11.2 g/dL\nLeukocyte count 7000/mm3\nSerum\nNa+ 148 mEq/L\nCl- 100 mEq/L\nK+ 3.8 mEq/L\nHCO3- 26 mEq/L\nUrea nitrogen 18 mg/L\nGlucose 90 mg/L\nCreatinine 0.8 mg/L\nOsmolality 300 mOsmol/kg H2O\nUrine osmolality 240 mOsm/kg H2O\nWhich of the following is the most likely explanation for this patient's hypernatremia?\"", "answer": "Decreased antidiuretic hormone secretion", "options": {"A": "Increased water intake", "B": "Increased adrenocorticotropin hormone secretion", "C": "Decreased antidiuretic hormone secretion", "D": "Decreased adrenocorticotropin hormone secretion"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "physician", "agitation", "confusion", "lethargy", "progressive recurring headaches", "visual impairment", "month", "Three days", "seizure", "not seen", "physician", "oriented only", "person", "temperature", "36", "98", "pulse", "90 min", "blood pressure", "80 mm Hg", "Capillary refill time", "more", "seconds", "laboratory studies show", "Hemoglobin", "g", "Leukocyte count", "mm3 Serum Na", "L", "100", "K", "HCO3", "18 mg", "0", "kg", "Urine", "mOsm", "following", "most likely explanation", "patient", "ypernatremia?"]}
{"question": "A 29-year-old woman presents to the physician with a blurred vision of her right eye for 2 days. She has pain around her right eye during eye movement. She takes no medications. At the clinic, her blood pressure is 110/70 mm Hg, the pulse is 72/min, respirations are 15/min, and the temperature is 36.5℃ (97.7℉). On physical examination, illumination of the left eye results in bilateral pupillary constriction while illumination of the right eye results in a mild bilateral pupillary dilation. Fundoscopic examination shows optic disk swelling in the right eye. The color vision test shows decreased perception in the right eye. The remainder of the physical examination shows no abnormalities. Specific additional history should be obtained regarding which of the following?", "answer": "Sensory loss", "options": {"A": "Dry eyes", "B": "High-risk sexual behaviour", "C": "Oral ulcers", "D": "Sensory loss"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["29 year old woman presents", "physician", "blurred vision", "right eye", "2 days", "pain around", "right eye", "eye movement", "takes", "medications", "clinic", "blood pressure", "70 mm Hg", "pulse", "72 min", "respirations", "min", "temperature", "36", "97", "physical examination", "illumination", "left eye results", "bilateral pupillary constriction", "illumination", "right eye results", "mild bilateral pupillary", "Fundoscopic examination shows optic disk swelling", "right eye", "color vision test shows decreased perception", "right eye", "physical examination shows", "abnormalities", "Specific additional history", "obtained", "following"]}
{"question": "A 25-year-old woman presents to her physician with complaints of cyclic vomiting for 3 days. The vomitus is watery and contains undigested food particles. She also complains of feeling tired and having the “sniffles”. She has not felt like eating or drinking since her symptoms started, and she has not taken any medications. Her concern now is that she immediately gets dizzy when she stands up. Vitals signs include: pulse 120/min, respiratory rate 9/min, and blood pressure 100/70 mm Hg. Her eyes are sunken, and her tongue appears dry. Which set of lab values would best correspond to this patient’s condition?", "answer": "pH = 7.5, Pco2 = 50 mm Hg, HCO32- = 38 mEq/L", "options": {"A": "pH = 7.5, Pco2 = 50 mm Hg, HCO32- = 38 mEq/L", "B": "pH = 7.2, Pco2 = 25 mm Hg, HCO32- = 30 mEq/L", "C": "pH = 7.5, Pco2 = 34 mm Hg, HCO32- = 38 mEq/L", "D": "pH = 7.5, Pco2 = 30 mm Hg, HCO32- = 24 mEq/L"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "physician", "complaints", "cyclic vomiting", "3 days", "vomitus", "watery", "contains undigested food", "feeling tired", "sniffles", "not felt", "eating", "drinking", "symptoms started", "not taken", "medications", "concern now", "immediately gets dizzy", "stands up", "signs include", "pulse", "min", "respiratory rate", "min", "blood pressure 100 70 mm Hg", "eyes", "tongue appears dry", "set", "lab values", "best", "patients condition"]}
{"question": "A 30-year-old male presents to his primary care physician complaining of infertility. He and his wife have been trying to get pregnant for the past two years. They have used fertility monitors and other aids without success. A hysterosalpingogram in his wife was normal. The patient has a history of cleft lip and recurrent upper respiratory infections as a child. He was briefly hospitalized for severe pneumonia when he was 9-years-old. His temperature is 98.6°F (37°C), blood pressure is 120/85 mmHg, pulse is 90/min, and respirations are 18/min. On examination, he is a healthy-appearing male in no acute distress with fully developed reproductive organs. Notably, cardiac auscultation is silent in the left 5th intercostal space at the midclavicular line. This patient most likely has a mutation in which of the following classes of proteins?", "answer": "Retrograde cytoskeletal motor protein", "options": {"A": "Microtubule monomeric protein", "B": "Transmembrane ion channel protein", "C": "Retrograde cytoskeletal motor protein", "D": "Anterograde cytoskeletal motor protein"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old male presents", "primary care physician", "infertility", "wife", "to", "pregnant", "past two years", "used fertility monitors", "aids", "success", "hysterosalpingogram", "wife", "normal", "patient", "history of cleft lip", "recurrent upper respiratory infections", "child", "hospitalized", "severe pneumonia", "years old", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "90 min", "respirations", "min", "examination", "healthy appearing male", "acute distress", "reproductive organs", "cardiac auscultation", "silent", "left 5th intercostal space", "midclavicular line", "patient", "likely", "a mutation", "following classes", "proteins"]}
{"question": "A 71-year-old woman with type 2 diabetes mellitus and hypertension comes to the emergency department because of a 3-day history of intermittent abdominal pain, vomiting, and obstipation. She has had multiple episodes of upper abdominal pain over the past year. She has smoked 1 pack of cigarettes daily for the past 30 years. Physical examination shows a distended abdomen with diffuse tenderness and high-pitched bowel sounds. An x-ray of the abdomen shows a dilated bowel, multiple air-fluid levels, and branching radiolucencies in the right infra-diaphragmatic region. Which of the following is the most likely cause of this patient's condition?", "answer": "Inflammation of the gallbladder wall", "options": {"A": "Perforation of the duodenal wall", "B": "Inflammation of the gallbladder wall", "C": "Obstruction of the common bile duct", "D": "Torsion of the large intestine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["71 year old woman", "type 2 diabetes mellitus", "hypertension", "emergency department", "3-day history", "intermittent abdominal pain", "vomiting", "obstipation", "multiple episodes of upper abdominal pain", "past year", "smoked 1 pack", "cigarettes daily", "past 30 years", "Physical examination shows", "distended abdomen", "diffuse tenderness", "high-pitched bowel sounds", "x-ray of", "abdomen shows", "dilated bowel", "multiple air-fluid levels", "branching radiolucencies", "right infra diaphragmatic region", "following", "most likely cause", "patient's condition"]}
{"question": "A 36-year-old man undergoes open reduction and internal fixation of a left femur fracture sustained after a motor vehicle collision. Three days after the surgery, he develops fever and redness around the surgical site. His temperature is 39.5°C (103.1°F). Physical examination shows purulent discharge from the wound with erythema of the surrounding skin. Wound culture of the purulent discharge shows gram-positive cocci in clusters. Treatment with oral dicloxacillin is initiated. Four days later, the patient continues to have high-grade fever, pain, and purulent discharge. Which of the following characteristics of the infecting organism best explains the failure to improve with antibiotic therapy?", "answer": "Adaptation in binding proteins", "options": {"A": "Presence of an impenetrable outer membrane", "B": "Ability to cleave β-lactam rings", "C": "Development of efflux pumps", "D": "Adaptation in binding proteins"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old man", "open reduction", "internal fixation of", "left femur fracture sustained", "motor vehicle collision", "Three days", "surgery", "fever", "redness", "surgical site", "temperature", "Physical examination shows purulent discharge from", "wound", "erythema of", "surrounding skin", "Wound culture", "purulent discharge shows gram-positive cocci in clusters", "Treatment", "oral dicloxacillin", "initiated", "Four days later", "patient continues to", "high-grade fever", "pain", "purulent discharge", "following characteristics", "infecting organism best", "failure to", "antibiotic therapy"]}
{"question": "A 45-year-old woman comes into your office with complaints of \"lump\" she found on her neck while showering. She denies any other symptoms and states that she has not gained any weight. On exam, you notice a 2 cm nodule on her anterior neck. Her TSH level is normal and radionucleotide scan reveals a cold nodule. Fine needle aspiration biopsy (FNAB) reveals follicular architecture suspicious for malignancy. What is the next best step?", "answer": "Surgical excision", "options": {"A": "Punch biopsy", "B": "Surgical excision", "C": "Thyroxine administration", "D": "Ultrasound"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "office", "complaints", "lump", "found", "neck", "showering", "denies", "symptoms", "states", "not gained", "weight", "exam", "2", "nodule", "anterior neck", "TSH level", "normal", "scan reveals", "cold nodule", "Fine needle aspiration biopsy", "reveals follicular architecture suspicious for malignancy", "next best step"]}
{"question": "While in the ICU, a 62-year-old male undergoes placement of a Swan-Ganz catheter to evaluate his right heart pressures. All pressures are found to be within normal limits, and the cardiology fellow records a pulmonary wedge pressure of 10 mmHg. Which of the following are normal values for the pressures that will be obtained from this patient's right ventricle?", "answer": "25/5 mmHg", "options": {"A": "25/10 mmHg", "B": "25/5 mmHg", "C": "10/0 mmHg", "D": "100/70 mmHg"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["ICU", "62 year old male", "placement", "Swan-Ganz catheter to evaluate", "right heart pressures", "pressures", "found to", "normal limits", "cardiology", "records", "pulmonary wedge pressure", "10 mmHg", "following", "normal values", "pressures", "obtained", "patient's"]}
{"question": "A 3-year-old boy is brought to the physician for a well-child examination. Over the past 8 months, his mother reports difficulty understanding the boy's speech. On occasion during this period, she has noticed that he does not respond when called by name and cannot follow 1-step instructions. He has a history of recurrent ear infections treated with antibiotics since birth. He is at the 60th percentile for length and 50th percentile for weight. Vital signs are within normal limits. His speech is quiet and difficult to understand. Otoscopic examination shows retracted tympanic membranes bilaterally that are immobile on pneumatic otoscopy. Nasopharyngoscopy shows mild adenoid hypertrophy. Pure tone audiometry shows a conductive hearing loss of 26 dB on the right side and 28 dB on the left side. Which of the following is the most appropriate next step in management?", "answer": "Tympanostomy tube insertion", "options": {"A": "Adenoidectomy", "B": "Tympanostomy tube insertion", "C": "Antihistamine therapy", "D": "Corticosteroid therapy\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 year old boy", "brought", "physician", "well", "past", "months", "mother reports difficulty understanding", "boy's speech", "occasion", "period", "not", "called", "name", "follow 1 step instructions", "history of recurrent ear infections treated with antibiotics", "birth", "percentile", "length", "50th percentile", "weight", "Vital signs", "normal limits", "speech", "quiet", "difficult to understand", "Otoscopic examination shows retracted tympanic membranes", "immobile", "pneumatic otoscopy", "Nasopharyngoscopy shows mild adenoid hypertrophy", "Pure tone audiometry shows", "conductive hearing loss", "dB", "right side", "dB", "left side", "following", "most appropriate next step", "management"]}
{"question": "A 42-year-old man is admitted to the intensive care unit with decreased consciousness and convulsions. His wife reports that 30 min following the onset of her husband’s condition, which started approximately 6 hours ago, he treated his garden bed with pesticides against mice. He developed nausea, vomiting, and abdominal cramps. The patient noted facial muscle twitching and developed a tonic-clonic seizure that lasted 3 minutes, 4 hours following the onset of his condition. His past medical history is insignificant for any seizure disorders, and he does not take any medications. His blood pressure is 95/60 mm Hg, heart rate is 104/min, respiratory rate is 10/min, and the temperature is 37.0°C (98.6°F). On physical examination, the patient’s consciousness is decreased with a Glasgow Coma Scale score of 13. He is pale and sweaty. His lung sounds are normal, cardiac sounds are decreased, and no murmurs are present. Abdominal palpation reveals epigastric tenderness. Neurological examination shows rapid downbeating nystagmus, facial muscle twitching, and symmetrically decreased sensation to all the sensory modalities on both the upper and lower extremities. Further discussion reveals that the patient was using sodium fluoroacetate as a pesticide, which is known to form fluorocitrate in the cells of aerobic organisms. Which of the following substances will accumulate in the patient’s cells?", "answer": "Citrate", "options": {"A": "Fumarate", "B": "Citrate", "C": "Malate", "D": "Succinate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "admitted to", "intensive care unit", "decreased consciousness", "convulsions", "wife reports", "30 min following", "onset", "husbands condition", "started approximately", "hours", "treated", "garden bed", "pesticides", "mice", "nausea", "vomiting", "abdominal cramps", "patient noted facial", "tonic-clonic seizure", "lasted 3 minutes", "4 hours following", "onset", "condition", "past medical history", "seizure disorders", "not take", "medications", "blood pressure", "95 60 mm Hg", "heart rate", "min", "respiratory rate", "10/min", "temperature", "98", "physical examination", "patients consciousness", "decreased", "Glasgow Coma Scale score", "13", "pale", "sweaty", "lung sounds", "normal", "cardiac sounds", "decreased", "murmurs", "present", "Abdominal palpation reveals epigastric tenderness", "Neurological examination shows rapid", "nystagmus", "facial", "decreased sensation", "sensory modalities", "upper", "lower extremities", "Further discussion reveals", "patient", "using sodium fluoroacetate", "pesticide", "known to form fluorocitrate", "cells", "aerobic organisms", "following substances", "patients cells"]}
{"question": "A 72-year-old woman presents to the emergency department with altered mental status. 90 minutes ago, the patient was found by a neighbor unarousable on the couch with multiple empty bottles of medication on the floor next to her. Social history is significant for alcohol abuse. Physical examination reveals an awake female with a fluctuating level of consciousness, not oriented to time or place. No focal neurologic deficits. Which of the following additional findings would most likely be present in this patient?", "answer": "Hallucinations", "options": {"A": "Hallucinations", "B": "Irreversibility", "C": "Multi-infarct dementia", "D": "Normal vital signs"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old woman presents", "emergency department", "altered mental status", "90 minutes", "patient", "found", "neighbor", "multiple empty bottles", "medication", "floor next to", "Social history", "significant", "alcohol abuse", "Physical examination reveals", "awake female", "fluctuating level of consciousness", "not oriented to time", "place", "focal neurologic deficits", "following additional findings", "most likely", "present", "patient"]}
{"question": "A 68-year-old man comes to the emergency department because of a cough, dyspnea, and fever for 1 day. The cough is productive of small amounts of green phlegm. He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago. He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year. His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler. He has smoked one pack of cigarettes daily for 48 years. His temperature is 39.1°C (103.1°F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Pulmonary examination shows diffuse crackles and rhonchi. An x-ray of the chest shows a left upper-lobe infiltrate of the lung. Two sets of blood cultures are obtained. Endotracheal aspirate Gram stain shows gram-negative rods. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate pharmacotherapy?", "answer": "Cefepime and levofloxacin", "options": {"A": "Ceftriaxone and azithromycin", "B": "Ertapenem", "C": "Colistin", "D": "Cefepime and levofloxacin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["68 year old man", "emergency department", "cough", "dyspnea", "fever", "1 day", "cough", "productive", "small amounts", "green phlegm", "metastatic colon cancer", "received three cycles", "chemotherapy", "5-fluorouracil", "leucovorin", "oxaliplatin", "last chemotherapy session", "2", "months", "chronic obstructive pulmonary disease", "treated with antibiotics", "prednisolone", "acute exacerbations three times", "past year", "medications include", "fluticasone-salmeterol inhaler", "tiotropium bromide inhaler", "smoked one pack", "cigarettes daily", "48 years", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "88 69 mm Hg", "Pulse oximetry", "room air shows", "oxygen", "88", "Pulmonary examination shows diffuse crackles", "rhonchi", "x-ray of", "chest shows", "left upper-lobe infiltrate of the lung", "sets", "blood cultures", "obtained", "Endotracheal aspirate Gram stain shows gram-negative rods", "Two large bore cannulas", "inserted", "intravenous fluids", "administered", "following", "most appropriate pharmacotherapy"]}
{"question": "A 21-year-old old college student is brought to the emergency department by his roommates because he has been \"acting strangely.\" Over the last 7 months, he has claimed to hear voices telling him that he must prepare for the end of the world. He used to be a straight A student but started failing exams recently due to his erratic behavior. Furthermore, there are periods of time where he does not sleep for several days and redecorates the entire apartment. During those times he spends huge amounts of money on online shopping. These periods usually last for about 2 weeks and happen every other month. On physical exam, he appears unkept and irritated. He seems to respond to invisible stimuli, and he jumps from topic to topic without clear focus. Which of the following is most consistent with this patient's presentation?", "answer": "Schizoaffective disorder", "options": {"A": "Brief psychotic disorder", "B": "Schizoaffective disorder", "C": "Schizophreniform disorder", "D": "Schizotypal personality disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["21-year-old", "college student", "brought", "emergency department", "roommates", "acting", "last", "months", "hear voices", "prepare", "end", "world", "used to", "straight", "student", "started failing exams recently due to", "behavior", "periods", "time", "not sleep", "days", "entire apartment", "times", "spends", "amounts", "money", "shopping", "periods usually last", "2 weeks", "happen", "month", "physical exam", "appears", "to", "invisible stimuli", "jumps", "topic", "topic", "clear focus", "following", "most consistent with", "patient", "resentation?"]}
{"question": "An 81-year-old man is brought to the clinic by his son to be evaluated for memory issues. The patient’s son says he has difficulty remembering recent events and names. He says the patient’s symptoms have progressively worsened over the last several years but became acutely worse just recently. Also, yesterday, the patient complained that he could not see out of his right eye, but today he can. When asked about these concerns, the patient seems to have no insight into the problem and reports feeling well. His medical history is significant for diabetes mellitus type 2 and hypertension. He had a left basal ganglia hemorrhage 12 years ago and a right middle cerebral artery infarction 4 years ago. Current medications are amlodipine, aspirin, clopidogrel, metformin, sitagliptin, and valsartan. He lives with his son and can feed himself and change his clothes. There is no history of urinary or fecal incontinence. His vitals include: blood pressure 137/82 mm Hg, pulse 78/min, respiratory rate 16/min, temperature 37.0°C (98.6°F). On physical examination, the patient is alert and oriented. He is unable to perform simple arithmetic calculations and the mini-mental status exam is inconclusive. He can write his name and comprehend written instructions. Muscle strength is 4/5 on the right side. The tone is also slightly reduced on the right side with exaggerated reflexes. His gait is hemiparetic. Which of the following is the most likely diagnosis in this patient?", "answer": "Vascular dementia", "options": {"A": "Alzheimer's disease", "B": "Lewy body dementia", "C": "Normal-pressure hydrocephalus", "D": "Vascular dementia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["81 year old man", "brought", "clinic", "son to", "evaluated", "memory issues", "patients son", "difficulty remembering recent events", "names", "patients symptoms", "worsened", "years", "worse", "recently", "patient", "not see out", "right eye", "today", "concerns", "patient", "to", "insight", "problem", "reports feeling well", "medical history", "significant", "diabetes mellitus type 2", "hypertension", "left", "years", "right middle cerebral artery infarction", "years", "Current medications", "amlodipine", "aspirin", "clopidogrel", "metformin", "sitagliptin", "valsartan", "lives with", "son", "feed", "change", "clothes", "history", "urinary", "fecal incontinence", "include", "blood pressure", "mm Hg", "pulse", "min", "respiratory rate", "min", "temperature", "98", "physical examination", "patient", "alert", "oriented", "unable to perform simple arithmetic calculations", "mini-mental status exam", "inconclusive", "write", "name", "written instructions", "Muscle strength", "4/5", "right side", "tone", "slightly reduced", "right side", "exaggerated reflexes", "gait", "following", "most likely diagnosis", "patient"]}
{"question": "A 46-year-old woman with a history of previously well-controlled HIV infection comes to the physician for follow-up after a health maintenance examination last week. She is currently unemployed and lives in a low-income neighborhood with her 3 children. For the past 3 years, her HIV RNA viral load was undetectable, but last week, her viral load was 8,391 copies/mL (N < 50). Current medications include dolutegravir, tenofovir, and emtricitabine. On questioning, she says that she misses her medications every other day. Which of the following responses by the physician is most appropriate?", "answer": "\"\"\"Let's talk about what makes it difficult for you to take your medications.\"\"\"", "options": {"A": "\"\"\"Let's talk about what makes it difficult for you to take your medications.\"\"\"", "B": "\"\"\"Are you aware that it is essential to take your medications every day?\"\"\"", "C": "\"\"\"The social worker can help subsidize next month's medications.\"\"\"", "D": "\"\"\"We should go over the instructions on how to take your medications again.\"\"\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "history", "well-controlled HIV infection", "physician", "follow-up", "health maintenance examination", "week", "currently unemployed", "lives", "low-income neighborhood", "children", "past", "years", "HIV RNA viral load", "undetectable", "last week", "viral load", "copies/mL", "N", "50", "Current medications include dolutegravir", "tenofovir", "emtricitabine", "questioning", "misses", "medications", "day", "following responses", "physician", "most appropriate"]}
{"question": "A 67-year-old man comes to the physician for a routine medical check-up prior to a scheduled elective femoropopliteal bypass surgery of his left leg. He feels well but reports occasional episodes of weakness and numbness in his left hand. He has a history of peripheral arterial disease, type 2 diabetes mellitus, hypertension, hypercholesterolemia, and gout. The patient has smoked 1 pack of cigarettes daily for the past 50 years. He drinks 3 cans of beer daily. His current medications include aspirin, metformin, enalapril, simvastatin, and febuxostat. His temperature is 37.3°C (99.1°F), pulse is 86/min, and blood pressure is 122/76 mm Hg. The lungs are clear to auscultation. Cardiac examination shows no murmurs, rubs, or gallops. Auscultation of the right side of the neck shows a bruit. There is a right-sided reducible inguinal hernia. Neurological examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, creatinine, and glucose are within the reference ranges. An electrocardiogram shows signs of mild left ventricular hypertrophy. An x-ray of the chest shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Ultrasonography of the neck", "options": {"A": "Ultrasonography of the neck", "B": "Echocardiography", "C": "Warfarin therapy", "D": "CT angiography of the head"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old man", "physician", "routine medical check-up prior to", "scheduled elective femoropopliteal bypass surgery", "left leg", "feels well", "reports occasional episodes of weakness", "numbness", "left", "history of peripheral arterial disease", "type 2 diabetes mellitus", "hypertension", "hypercholesterolemia", "gout", "patient", "smoked 1 pack", "cigarettes daily", "past 50 years", "drinks 3 cans", "beer daily", "current medications include aspirin", "metformin", "enalapril", "simvastatin", "febuxostat", "temperature", "3C", "99", "pulse", "min", "blood pressure", "76 mm Hg", "lungs", "clear", "auscultation", "Cardiac shows", "murmurs", "rubs", "Auscultation of", "right side", "neck shows", "bruit", "right-sided reducible inguinal hernia", "Neurological examination shows", "abnormalities", "complete blood count", "serum", "electrolytes", "creatinine", "glucose", "reference ranges", "electrocardiogram shows signs", "mild left ventricular hypertrophy", "x-ray of", "chest shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 35-year-old woman presents to her primary care provider concerned that she may be pregnant. She has a history of regular menstruation every 4 weeks that lasts about 4 days with mild to moderate bleeding, but she missed her last period 2 weeks ago. A home pregnancy test was positive. She has a 6-year history of hyperthyroidism that is well-controlled with daily methimazole. She is currently asymptomatic and has no complaints or concerns. A blood specimen is taken and confirms the diagnosis. Additionally, her thyroid-stimulating hormone (TSH) is 2.0 μU/mL. Which of the following is the next best step in the management of this patient?", "answer": "Discontinue methimazole, start propylthiouracil", "options": {"A": "Continue methimazole", "B": "Discontinue methimazole, start propylthiouracil", "C": "Add glucocorticoids", "D": "Refer for radioiodine therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old woman presents", "primary care provider concerned", "pregnant", "history", "regular menstruation", "4 weeks", "lasts", "4 days", "mild to moderate bleeding", "missed", "last period", "weeks", "home pregnancy test", "positive", "year history of hyperthyroidism", "well-controlled", "daily methimazole", "currently asymptomatic", "complaints", "concerns", "blood specimen", "taken", "confirms", "diagnosis", "thyroid-stimulating hormone", "2 0 U/mL", "following", "next best step", "management", "patient"]}
{"question": "A 65-year-old man presents to the emergency department with back pain. The patient states that he has gradually worsening back pain that seems to have worsened after moving furniture the other day. He also states that while he walks, he feels numbness and weakness in his legs. The only time the patient states his back pain is improved is when he is riding his bike or pushing a cart at the grocery store. The patient has a past medical history of osteoporosis, dyslipidemia, and diabetes. He drinks 3 alcoholic drinks every day and has a 44 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 157/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-tender spine with normal mobility in all 4 directions. Radiography of the spine and basic labs are ordered. Which of the following is the most likely diagnosis?", "answer": "Spinal stenosis", "options": {"A": "Compression fracture", "B": "Herniated nucleus pulposus", "C": "Musculoskeletal strain", "D": "Spinal stenosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man presents", "emergency department", "back pain", "patient states", "worsening back pain", "to", "worsened", "moving furniture", "day", "states", "walks", "feels numbness", "weakness", "legs", "only time", "patient states", "back pain", "improved", "bike", "pushing", "cart", "grocery store", "patient", "past medical", "dyslipidemia", "diabetes", "drinks 3 alcoholic drinks", "day", "pack-year smoking history", "temperature", "99", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "non-tender spine", "normal mobility", "directions", "Radiography of", "spine", "basic labs", "ordered", "following", "most likely diagnosis"]}
{"question": "A 3-year-old girl is brought to the physician because of a 3-day history of fever, cough, purulent nasal discharge. She has experienced 7 similar episodes, each lasting 2–5 days in the previous 2 years. She has also had intermittent abdominal cramps and recurrent episodes of foul-smelling greasy diarrhea in the past year. She is at the 55th percentile for height and 35th percentile for weight. Her temperature is 38.9°C (102°F), pulse is 100/min, respirations are 24/min, and blood pressure is 110/60 mm Hg. Physical examination shows an erythematous oropharynx without exudate and tenderness over the frontoethmoidal sinuses. The abdomen is distended, nontender, and tympanitic to percussion. Bowel sounds are increased. Stool microscopy shows pear-shaped multi-flagellated organisms. This patient is at increased risk for which of the following?", "answer": "Anaphylactic transfusion reactions", "options": {"A": "Anaphylactic transfusion reactions", "B": "Cutaneous granulomas", "C": "Non-Hodgkin lymphoma", "D": "Disseminated tuberculosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "physician", "3-day history", "fever", "cough", "purulent nasal discharge", "experienced", "similar episodes", "lasting", "days", "previous 2 years", "intermittent abdominal cramps", "recurrent episodes of", "smelling greasy diarrhea", "past year", "percentile", "height", "percentile", "weight", "temperature", "pulse", "100 min", "respirations", "min", "blood pressure", "60 mm Hg", "Physical examination shows", "erythematous oropharynx", "exudate", "tenderness", "sinuses", "abdomen", "distended", "nontender", "tympanitic", "percussion", "Bowel sounds", "increased", "Stool microscopy shows pear-shaped multi flagellated organisms", "patient", "increased risk", "following"]}
{"question": "An 8-year-old boy who recently immigrated to the United States presents with a rash. Past medical history is significant for a recent sore throat which caused him to miss several days at school. The patient’s vaccination status is unknown. On physical examination, the patient is pale and ill-looking. There are pink rings present on the torso and inner surfaces of the limbs. Cardiac exam is significant for a holosystolic murmur heard best over the apex of the heart. Which of the following histopathologic findings is most likely associated with this patient’s condition?", "answer": "Granulomas with giant cells", "options": {"A": "Atypical lymphocytes on peripheral blood smear", "B": "Starry sky appearance", "C": "Needle-shaped, negatively birefringent crystal deposits", "D": "Granulomas with giant cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "recently", "United States presents", "rash", "Past medical history", "significant", "recent sore throat", "caused", "to miss several days", "school", "patients vaccination status", "unknown", "physical examination", "patient", "pale", "ill looking", "pink rings present", "torso", "inner surfaces of", "limbs", "Cardiac exam", "significant", "holosystolic murmur heard best", "the apex of", "heart", "following histopathologic findings", "most likely associated with", "patients condition"]}
{"question": "A 59-year-old man presents to general medical clinic for his yearly checkup. He has no complaints except for a dry cough. He has a past medical history of type II diabetes, hypertension, hyperlipidemia, asthma, and depression. His home medications are sitagliptin/metformin, lisinopril, atorvastatin, albuterol inhaler, and citalopram. His vitals signs are stable, with blood pressure 126/79 mmHg. Hemoglobin A1C is 6.3%, and creatinine is 1.3 g/dL. The remainder of his physical exam is unremarkable. If this patient's cough is due to one of the medications he is taking, what would be the next step in management?", "answer": "Change lisinopril to losartan", "options": {"A": "Change lisinopril to propanolol", "B": "Change lisinopril to amlodipine", "C": "Change atorvastatin to to lovastatin", "D": "Change lisinopril to losartan"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["59 year old man presents", "general medical clinic", "yearly checkup", "complaints", "dry cough", "a past medical type II diabetes", "hypertension", "hyperlipidemia", "asthma", "depression", "home medications", "sitagliptin/metformin", "lisinopril", "atorvastatin", "albuterol inhaler", "citalopram", "signs", "stable", "blood pressure", "mmHg", "Hemoglobin A1C", "6.3", "creatinine", "1", "g/dL", "physical exam", "unremarkable", "patient's cough", "due to one", "medications", "next step", "management"]}
{"question": "A male newborn is evaluated 24 hours after delivery for high-pitched crying, poor feeding, rhinorrhea, and low-grade fever. He was born at 40 weeks' gestation at 2514 g (5.54 lb) to a 28-year-old woman, gravida 3, para 2, by an uncomplicated cesarean section. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The mother did not receive prenatal care. The infant's temperature is 38.0°C (100.4°F), pulse is 170/min, and blood pressure is 71/39 mm Hg. Examination shows hyperreflexia, tremors, and an excessive startle response. These symptoms are mostly like due to maternal use of which of the following?", "answer": "Mu receptor agonist", "options": {"A": "Mu receptor agonist", "B": "Nicotinic acetylcholine receptor agonist", "C": "Monoamine reuptake antagonist", "D": "Thyroperoxidase inhibitor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["male newborn", "evaluated 24 hours", "delivery", "high-pitched crying", "poor feeding", "rhinorrhea", "low-grade fever", "born", "40 weeks", "gestation", "g", "54", "year old woman", "gravida 3", "para 2", "uncomplicated cesarean section", "Apgar scores", "5 minutes", "mother", "not receive prenatal care", "infant's temperature", "100 4F", "pulse", "min", "blood pressure", "71", "mm Hg", "Examination shows hyperreflexia", "tremors", "excessive startle response", "symptoms", "mostly", "due to maternal use of"]}
{"question": "A previously healthy 35-year-old primigravid woman at 12 weeks' gestation comes to the physician because of a fever, persistent headache, nausea, and abdominal discomfort for 1 week. During this time, she has also noticed that her gums bleed while brushing her teeth. A month ago, she returned from a camping trip to Sri Lanka. Her temperature is 39.3°C (102.8°F), pulse is 104/min, respirations are 24/min, and blood pressure is 135/88 mm Hg. Examination shows pallor and mild scleral icterus. There are a few scattered petechiae over the trunk and back. There is no lymphadenopathy. Physical and neurologic examinations show no other abnormalities. Test of the stool for occult blood is positive. Laboratory studies show:\nHemoglobin 8.2 g/dL\nLeukocyte count 10,000/mm3\nPlatelet count 18,000/mm3\nINR 1.0\nCoomb's test negative\nFibrin split products negative\nSerum\nUrea 20 mg/dL\nCreatinine 1.1 mg/dL\nBilirubin\nTotal 3.0 mg/dL\nDirect 0.8 mg/dL\nAlanine aminotransferase 20 U/L\nAspartate aminotransferase 16 U/L\nLactate dehydrogenase 900 U/L\nUrine\nProtein 1+\nWBCs occasional\nRBCs 50–60/hpf\nBacteria nil\nA photograph of the peripheral blood smear is shown. Blood and urine cultures are negative. Which of the following is the most likely diagnosis?\"", "answer": "Thrombotic thrombocytopenic purpura", "options": {"A": "HELLP syndrome", "B": "Thrombotic thrombocytopenic purpura", "C": "Hemolytic uremic syndrome", "D": "Autoimmune hemolytic anemia\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy 35 year old primigravid woman", "weeks", "estation ", "hysician ", "ever,", "ersistent headache,", "ausea,", "bdominal discomfort ", " week.", "ime,", "ums  leed ", "rushing ", "eeth.", "onth ", "eturned ", "amping  rip ", "ri Lanka.", "emperature ", "C ", "ulse ", "in,", "espirations ", "in,", "lood pressure ", "8  m Hg.", "xamination  hows  allor ", "ild  cleral icterus.", "ew  cattered  etechiae ", "runk ", "ack.", "ymphadenopathy.", "hysical ", "eurologic examinations  how ", "bnormalities.", "est ", "tool ", "ccult blood ", "ositive.", "aboratory studies  how:", "emoglobin 8.", "/ eukocyte  0,", "m3  latelet count  8,", "NR  .   oomb'", "st n gative F brin split products n", "rum U ea 2", "/d", "eatinine 1", "lirubin Total 3", "rect 0 8 m /dL A anine aminotransferase 2  U L A partate aminotransferase 1  U", "0 U", "ine P", "Cs o casional R Cs 5", "f B", "l A", "otograph o", "ripheral blood smear i", "own. ", "ood a", "ine cultures a", "gative. ", "llowing i", "st likely d agnosis?\""]}
{"question": "A 36-year-old man is brought to the emergency department 40 minutes after being involved in a shooting. He sustained a gunshot wound in an altercation outside of a bar. On arrival, he is oriented to person but not to place or time. His temperature is 37.3°C (99.1°F), pulse is 116/min, respirations are 18/min, and blood pressure is 79/42 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. Examination shows multiple abrasions over the arms and thorax. There is a 1-cm (0.4-in) entry wound with minimal bleeding on the right side of the chest in the 6th intercostal space at the midclavicular line. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows diffuse mild tenderness to palpation with no guarding or rebound. A focused assessment with sonography shows no obvious free fluid in the pericardium; assessment of the abdomen is equivocal. An x-ray of the chest shows mild opacification of the right lower lobe. Two large-bore cannulas are inserted and intravenous fluid resuscitation is begun. The patient is intubated and mechanical ventilation is begun. Which of the following is the most appropriate next step in management?", "answer": "Exploratory laparotomy", "options": {"A": "CT scan of the chest, abdomen, and pelvis", "B": "Local wound exploration", "C": "Exploratory laparotomy", "D": "Video-assisted thoracoscopic surgery"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old man", "brought", "emergency department 40 minutes", "involved", "shooting", "sustained", "gunshot wound", "altercation", "bar", "arrival", "oriented to person", "not to place", "time", "temperature", "3C", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "97", "Examination shows multiple abrasions", "arms", "thorax", "0.4", "entry wound", "minimal bleeding", "right side of", "chest", "intercostal space", "midclavicular line", "Cardiopulmonary examination shows", "abnormalities", "Abdominal examination shows diffuse mild tenderness", "palpation", "guarding", "focused assessment", "sonography shows", "free fluid in", "pericardium", "assessment", "abdomen", "equivocal", "x-ray of", "chest shows mild opacification", "right lower lobe", "Two large bore cannulas", "inserted", "intravenous", "begun", "patient", "intubated", "mechanical ventilation", "begun", "following", "most appropriate next step", "management"]}
{"question": "Mutations in the ATP2A1 gene results in loss of function of the calcium ATPase pump, which is in the sarcoplasmic reticulum membranes of skeletal muscle in humans. This mutation results in a rare disease characterized by muscle cramping and stiffening that is usually most severe after exercise or strenuous activity and is typically relieved after affected individuals rest for a few minutes. Which of the following is expected in individuals with an ATP2A1 gene mutation?", "answer": "Muscle relaxation time: increased, cytosolic calcium concentration: increased", "options": {"A": "Muscle relaxation time: decreased, cytosolic calcium concentration: increased", "B": "Muscle relaxation time: increased, cytosolic calcium concentration: increased", "C": "Muscle relaxation time: increased, cytosolic calcium concentration: no change", "D": "Muscle relaxation time: no change, cytosolic calcium concentration: decreased"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["Mutations", "ATP2A1 results", "loss", "function", "calcium pump", "sarcoplasmic reticulum membranes", "skeletal muscle", "humans", "mutation results", "rare characterized", "muscle cramping", "usually", "severe", "exercise", "strenuous activity", "relieved", "affected individuals rest", "minutes", "following", "expected", "individuals", "ATP2A1"]}
{"question": "A 62-year-old man presents to the emergency department with crushing chest pain (10/10 in severity), radiating to the left side of the neck and the left arm. His symptoms started 20 minutes ago while shaving. He also feels nauseated, lightheaded and short of breath. He has had type 2 diabetes for 27 years and essential hypertension for 19 years. He has smoked 20–30 cigarettes per day for the past 35 years. Family history is irrelevant. His temperature is 36.9°C (98.4°F), the blood pressure is 115/72 mm Hg and the pulse is 107/min. Physical examination is unremarkable. ECG is shown in the image. Troponins are elevated. The patient is admitted to a unit with continuous cardiac monitoring. Aspirin, clopidogrel, sublingual nitroglycerin, and morphine are given immediately and the patient now rates the pain as 4–5 out of 10. Which of the following is the best next step in the management of this patient condition?", "answer": "Percutaneous coronary intervention", "options": {"A": "Percutaneous coronary intervention", "B": "Intravenous alteplase", "C": "Coronary artery bypass graft", "D": "Oral ramipril"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man presents", "emergency department", "crushing chest pain", "10", "severity", "radiating", "left side of", "neck", "left arm", "symptoms started 20 minutes", "shaving", "feels nauseated", "lightheaded", "short of breath", "type 2 diabetes", "27 years", "essential hypertension", "years", "smoked", "cigarettes", "day", "past 35 years", "Family history", "temperature", "36", "98 4F", "blood pressure", "72 mm Hg", "pulse", "min", "Physical examination", "unremarkable", "ECG", "shown", "image", "Troponins", "elevated", "patient", "admitted", "unit", "continuous cardiac monitoring", "Aspirin", "clopidogrel", "sublingual nitroglycerin", "morphine", "given immediately", "patient now rates", "pain", "10", "following", "best next step", "management", "patient"]}
{"question": "A 54-year-old man comes to the emergency department because of a 2-day history of increasingly severe abdominal pain, nausea, and bilious vomiting. His last bowel movement was yesterday and he has not passed flatus since then. He underwent appendectomy at the age of 39. He has psoriasis, hypertension, type 2 diabetes mellitus, and chronic back pain. He drinks two beers daily. He takes a topical corticosteroid, ramipril, metformin, and ibuprofen daily. He is 176 cm (5 ft 9 in) tall and weighs 108 kg (240 lb); BMI is 35.4 kg/m2. His temperature is 36.8°C (98.4°F), respirations are 15/min, pulse is 90/min, and blood pressure is 112/67 mm Hg. Examination shows thick, scaly, plaques over both elbows and knees. Abdominal examination shows three well-healed laparoscopic scars. The abdomen is distended and there are frequent, high-pitched bowel sounds on auscultation. Digital rectal examination shows an empty rectum. Laboratory studies show:\nHematocrit 44%\nLeukocyte count 9,000/mm3\nPlatelet count 225,000/mm3\nSerum\nNa+ 139 mEq/L\nK+ 4.1 mEq/L\nCl− 101 mEq/L\nHCO3− 26 mEq/L\nGlucose 95 mg/dL\nCreatinine 1.1 mg/dL\nAlkaline phosphatase 78 U/L\nAspartate aminotransferase (AST, GOT) 19 U/L\nAlanine aminotransferase (ALT, GPT) 14 U/L\nγ-Glutamyltransferase (GGT) 52 U/L (N=5–50 U/L)\nHemoglobin A1C 6.4%\nAbdominal ultrasound shows nonpropulsive peristalsis of the small bowel. Which of the following is the most likely cause of this patient's condition?\"", "answer": "History of abdominal surgery", "options": {"A": "Chronic inflammatory bowel disease", "B": "Ibuprofen", "C": "History of abdominal surgery", "D": "Alcohol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["54 year old man", "emergency department", "2-day history", "severe abdominal", "nausea", "bilious vomiting", "last bowel movement", "not passed flatus", "then", "appendectomy", "age", "psoriasis", "hypertension", "type 2 diabetes mellitus", "chronic back pain", "drinks two beers daily", "takes", "topical corticosteroid", "ramipril", "metformin", "ibuprofen daily", "5 ft 9", "tall", "kg", "BMI", "35", "kg/m2", "temperature", "36", "98 4F", "respirations", "min", "pulse", "90 min", "blood pressure", "67 mm Hg", "Examination shows thick", "scaly", "plaques", "elbows", "knees", "Abdominal examination shows three well healed laparoscopic scars", "abdomen", "distended", "frequent", "high-pitched bowel sounds", "auscultation", "Digital rectal examination shows", "empty rectum", "Laboratory studies show", "Hematocrit", "Leukocyte", "mm3 Platelet count", "Serum", "mEq", "HCO3", "95 mg dL Creatinine", "dL Alkaline phosphatase", "U", "Aspartate aminotransferase", "AST", "U/L Alanine aminotransferase", "ALT", "GPT", "U/L", "Glutamyltransferase", "GGT", "U/L", "N 550 U/L", "Hemoglobin A1C", "Abdominal ultrasound shows", "peristalsis", "small bowel", "following", "most likely cause", "patient", "ondition?"]}
{"question": "A 28-year-old Caucasian woman presents to your office with recurrent abdominal cramping on her left side for 6 months. She additionally reports bloody diarrhea and tenesmus. You suspect ulcerative colitis. Which of the following findings would most strongly confirm your diagnosis?", "answer": "Continuous mucosal damage", "options": {"A": "Involvement of terminal ileum", "B": "Noncaseating granulomas", "C": "Transmural inflammation", "D": "Continuous mucosal damage"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old Caucasian woman presents", "office", "recurrent abdominal cramping", "left side", "months", "reports bloody diarrhea", "tenesmus", "suspect ulcerative colitis", "following findings", "most", "confirm", "diagnosis"]}
{"question": "A 6-month-old boy is brought to the physician by his parents for difficulty breathing and bluish discoloration of the lips for the past hour. During the past 3 months, the patient has had several upper respiratory tract infections and poor weight gain. Physical examination shows crackles over both lung fields and enlargement of the tonsils and cervical lymph nodes. His serum IgA, IgE, and IgG titers are decreased. An x-ray of the chest shows bilateral interstitial infiltrates. Methenamine silver staining of bronchial lavage fluid shows disc-shaped cysts. A defect in which of the following is the most likely underlying cause of this patient's condition?", "answer": "T-cell receptor signaling", "options": {"A": "Actin filament assembly", "B": "T-cell receptor signaling", "C": "Microtubule polymerization", "D": "B-cell maturation"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "physician", "parents", "difficulty breathing", "discoloration", "lips", "past hour", "past 3 months", "patient", "several upper respiratory tract infections", "poor weight gain", "Physical examination shows crackles", "lung fields", "enlargement of", "tonsils", "cervical lymph nodes", "serum IgA", "titers", "decreased", "x-ray of", "chest shows bilateral interstitial", "Methenamine silver staining of bronchial lavage fluid shows disc-shaped cysts", "defect", "following", "most likely underlying cause", "patient's condition"]}
{"question": "A 67-year-old man comes to the clinic complaining of fatigue and dizziness for the past 2 months. He reports that he gets tired easily compared to his baseline and feels dizzy when he exerts himself (e.g., when he walks long distances). His past medical history is significant for hypertension that is controlled with lisinopril. A physical examination demonstrates moderate hepatomegaly and lymphadenopathy. His laboratory studies are shown below.\n\nLeukocyte count and differential:\nLeukocyte count: 11,500/mm^3\nSegmented neutrophils: 40%\nBands: 3%\nEosinophils: 1%\nBasophils: 0%\nLymphocytes: 50%\nMonocytes: 8%\n\nHemoglobin: 11.2 g/dL\nPlatelet count: 120,000/mm^3\nMean corpuscular hemoglobin concentration: 31%\nMean corpuscular volume: 80 µm^3\nReticulocyte count: 3%\nLactate dehydrogenase: 45 U/L\n\nA subsequent flow cytometry test demonstrates CD20+ cells. What is the most likely finding you would expect in this patient?", "answer": "Presence of smudge cells", "options": {"A": "Low levels of erythropoietin", "B": "Low levels of leukocyte alkaline phosphatase (LAP)", "C": "Presence of hairy cells", "D": "Presence of smudge cells"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["67 year old man", "clinic", "fatigue", "dizziness", "past", "months", "reports", "gets tired easily compared", "baseline", "feels dizzy", "exerts", "walks long distances", "past medical history", "significant", "hypertension", "controlled", "lisinopril", "physical examination demonstrates moderate hepatomegaly", "lymphadenopathy", "laboratory studies", "shown", "Leukocyte count", "differential", "Leukocyte count", "500 mm", "Segmented neutrophils", "40", "Bands", "3", "Eosinophils", "1", "Basophils", "0", "Lymphocytes", "50", "Monocytes", "Hemoglobin", "g/dL Platelet count", "mm", "Mean corpuscular hemoglobin concentration", "31", "Mean corpuscular volume", "80 m", "Reticulocyte count", "3", "Lactate dehydrogenase", "U/L", "subsequent flow cytometry test demonstrates CD20", "cells", "most likely finding", "patient"]}
{"question": "A 81-year-old man is brought to the emergency department after he fell asleep at the dinner table and was not able to be roused by his family. His past medical history is significant for Alzheimer disease though he is still relatively functional at baseline. He has also been taking warfarin over the last 3 months after he suffered a deep venous thrombosis. After he was transported to the ED, his family found that the pills his grandson takes for seizures were missing. On presentation, he is found to be somnolent and physical exam reveals ataxia and nystagmus. After determining the cause of this patient's symptoms, his physicians begin monitoring his international normalized ratio, because they are concerned that it will start trending down. Which of the following treatments would most improve the urinary excretion of the substance likely responsible for these symptoms?", "answer": "Sodium bicarbonate", "options": {"A": "Ammonium chloride", "B": "Mannitol", "C": "Sodium bicarbonate", "D": "Thiazide diuretics"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["81 year old man", "brought", "emergency department", "fell asleep", "dinner table", "not able to", "family", "past medical history", "significant", "Alzheimer disease", "functional", "baseline", "taking warfarin", "months", "suffered", "deep venous thrombosis", "transported", "ED", "family found", "pills", "grandson takes", "seizures", "missing", "presentation", "found to", "somnolent", "physical exam reveals ataxia", "nystagmus", "cause", "patient's symptoms", "physicians begin monitoring", "international normalized ratio", "concerned", "start trending", "following treatments", "most", "urinary excretion", "substance likely responsible", "symptoms"]}
{"question": "A 10-year-old girl is brought to the physician because of high-grade fever, myalgia, and generalized fatigue for 3 days. She returned from a vacation to northern Brazil 4 days ago. She took the appropriate medications and immunizations prior to her visit. There is no family history of serious illness. She appears ill. Her temperature is 39.4°C (103°F), pulse is 110/min and blood pressure is 94/54 mm Hg. Examination shows jaundice of the conjunctivae and skin. The abdomen is soft and nontender; the spleen is palpated 2 to 3 cm below the left costal margin. Laboratory studies show:\nHemoglobin 10.1 g/dL\nLeukocyte count 4,650/mm3\nPlatelet count 200,000/mm3\nSerum\nGlucose 56 mg/dL\nCreatinine 0.8 mg/dL\nBilirubin\nTotal 4.7 mg/dL\nDirect 0.9 mg/dL\nLactate dehydrogenase 212 U/L\nWhich of the following is the most likely to confirm the diagnosis?\"", "answer": "Thick and thin blood smear", "options": {"A": "Thick and thin blood smear", "B": "Direct antiglobulin test", "C": "Sickle cell test", "D": "Ultrasound of the abdomen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["A 10 year old girl", "brought", "physician", "high-grade fever", "myalgia", "generalized fatigue", "3 days", "returned", "vacation", "northern Brazil", "days", "took", "appropriate medications", "immunizations prior to", "visit", "family history", "serious illness", "appears ill", "temperature", "4C", "pulse", "min", "blood pressure", "54 mm Hg", "Examination shows jaundice", "conjunctivae", "skin", "abdomen", "soft", "nontender", "spleen", "palpated 2", "3 cm", "left costal margin", "Laboratory studies show", "10", "g/dL Leukocyte count 4 650 mm3 Platelet count 200", "Serum", "Creatinine 0", "Bilirubin", "7", "Direct 0.9 mg/dL Lactate dehydrogenase", "U L", "following", "most likely to confirm", "diagnosis"]}
{"question": "A 56-year-old woman presents to a physician with severe pain and swelling of the left inguinal area for 3 days. She has a fever and malaise. Last week she noted several painless red papules on her left thigh when she was on a summer trip to Madagascar. She has no history of serious illnesses and is on no medications. There has been no recent contact with any animals or pets. The temperature is 38.6℃ (101.5℉), the pulse is 78/min, the respiration rate is 12/min, and the blood pressure is 110/65 mm Hg. Swelling of the left inguinal area was noted; however, there were no skin changes. Several large, tense, and tender lymph nodes with a boggy consistency were palpated in the inguinal region. The right inguinal area is normal on physical exam. There was no lymphadenopathy in other areas. No abnormalities existed in the lungs, heart, and abdomen. Microscopic examination of pus from the inguinal lymph nodes revealed gram-negative Coccobacilli. Serum anti-F1 titers show a 4-fold rise. Which of the following is the most appropriate pharmacotherapy at this time?", "answer": "Streptomycin", "options": {"A": "Azithromycin", "B": "Imipenem", "C": "Streptomycin", "D": "No pharmacotherapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physician", "severe pain", "swelling", "left inguinal area", "3 days", "fever", "malaise", "week", "noted several painless red papules", "left thigh", "summer trip", "Madagascar", "history", "serious illnesses", "medications", "recent contact with", "animals", "pets", "temperature", "pulse", "min", "respiration rate", "min", "blood pressure", "65 mm Hg", "Swelling", "left inguinal area", "noted", "skin changes", "large", "tense", "tender lymph nodes with", "boggy consistency", "palpated", "inguinal region", "right inguinal area", "normal", "physical exam", "lymphadenopathy", "areas", "abnormalities existed", "lungs", "heart", "abdomen", "Microscopic examination of pus", "inguinal lymph nodes revealed gram-negative Coccobacilli", "Serum", "titers show", "4 fold rise", "following", "most appropriate pharmacotherapy", "time"]}
{"question": "A 60-year-old woman is brought to the emergency department because of sudden, painless loss of vision in her right eye that occurred 30 minutes ago while watching TV. She has coronary artery disease, hypertension, and type 2 diabetes mellitus; she has had trouble adhering to her medication regimen. Her blood pressure is 160/85 mm Hg. Examination shows 20/50 vision in the left eye and no perception of light in the right eye. Direct pupillary reflex is present in the left eye, but absent in the right eye. Accommodation is intact bilaterally. Intraocular pressure is 16 mm Hg in the left eye and 18 mm Hg in the right eye. Fundoscopic examination of the right eye shows a pale, white retina with a bright red area within the macula. The optic disc appears normal. Which of the following is the most likely diagnosis?", "answer": "Central retinal artery occlusion", "options": {"A": "Retinal detachment", "B": "Central retinal artery occlusion", "C": "Acute angle-closure glaucoma", "D": "Anterior ischemic optic neuropathy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["60 year old woman", "brought", "emergency department", "of sudden", "painless loss", "vision", "right eye", "occurred 30 minutes", "watching TV", "coronary artery disease", "hypertension", "type 2 diabetes mellitus", "adhering", "medication regimen", "blood pressure", "85 mm Hg", "Examination shows 20/50 vision", "left", "perception of light", "right eye", "Direct pupillary", "present", "left eye", "absent", "right eye", "Accommodation", "intact", "Intraocular pressure", "mm Hg", "left eye", "mm Hg", "right eye", "Fundoscopic examination of", "shows", "pale", "white retina", "bright area", "macula", "optic disc appears normal", "following", "most likely diagnosis"]}
{"question": "A previously healthy 35-year-old woman comes to the emergency department because of sudden weakness of her right arm and leg that started 3 hours ago. She returned from a business trip from Europe 3 days ago. She has smoked a pack of cigarettes daily for 10 years. Her only medication is an oral contraceptive. Her temperature is 38.0°C (100.4°F), pulse is 115/min and regular, and blood pressure is 155/85 mm Hg. Examination shows decreased muscle strength on the entire right side. Deep tendon reflexes are 4+ on the right. Babinski sign is present on the right. The left lower leg is swollen, erythematous, and tender to palpation. Further evaluation is most likely to show which of the following?", "answer": "Patent foramen ovale", "options": {"A": "Patent foramen ovale", "B": "Mitral valve vegetation", "C": "Atrial fibrillation", "D": "Carotid artery dissection"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy 35 year old woman", "emergency department", "of sudden weakness", "right arm", "leg", "started 3 hours", "returned", "business trip", "Europe", "days", "smoked", "pack", "cigarettes daily", "10 years", "only medication", "oral contraceptive", "temperature", "100 4F", "pulse", "min", "regular", "blood pressure", "85 mm Hg", "Examination shows decreased muscle strength", "entire right side", "Deep tendon reflexes", "4", "right", "Babinski sign", "present", "right", "left lower leg", "swollen", "erythematous", "tender", "palpation", "Further evaluation", "most likely to show", "following"]}
{"question": "A 24-year-old woman is brought to the emergency room (ER) by her co-workers after they found her unconscious in her cubicle when they returned from lunch. They tell you that she has diabetes but do not know anything more about her condition. The woman’s vital signs include: pulse 110/min, respiratory rate 24/min, temperature 36.7°C (98.0°F), and blood pressure 90/60 mm Hg. On physical examination, the patient is breathing heavily and gives irrelevant responses to questions. The skin and mucous membranes appear dry. Examination of the abdomen reveals mild diffuse tenderness to palpation. Deep tendon reflexes in the extremities are 1+ bilaterally. Laboratory studies show:\nFinger stick glucose 630 mg/dL\nArterial blood gas analysis:\npH 7.1\nPO2 90 mm Hg\nPCO2 33 mm Hg\nHCO3 8 mEq/L\nSerum:\nSodium 135 mEq/L\nPotassium 3.1 mEq/L\nChloride 136 mEq/L\nBlood urea nitrogen 20 mg/dL\nSerum creatinine 1.2 mg/dL\nUrine examination shows:\nGlucose Positive\nKetones Positive\nLeukocytes Negative\nNitrite Negative\nRBCs Negative\nCasts Negative\nThe patient is immediately started on a bolus of intravenous (IV) 0.9% sodium chloride (NaCl). Which of the following is the next best step in the management of this patient?", "answer": "Replace potassium intravenously", "options": {"A": "Infuse NaHCO3 slowly", "B": "Switch fluids to 0.45% NaCl", "C": "Start IV insulin infusion", "D": "Replace potassium intravenously"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency room", "co workers", "found", "unconscious", "returned", "lunch", "diabetes", "not", "more", "condition", "vital signs include", "pulse", "min", "respiratory rate", "min", "temperature 36", "98", "blood pressure 90 60 mm Hg", "physical examination", "patient", "breathing", "gives", "responses", "questions", "skin", "mucous membranes appear dry", "Examination of", "abdomen reveals mild diffuse tenderness", "palpation", "Deep tendon reflexes", "extremities", "1", "Laboratory studies show", "Finger stick glucose", "mg/dL Arterial blood gas analysis", "pH", "PO2 90 mm Hg PCO2", "HCO3", "mEq/L Serum", "Sodium", "mEq", "dL Serum", "Urine examination shows", "Glucose Positive Ketones", "Leukocytes Negative Nitrite", "RBCs", "Casts Negative", "patient", "immediately started", "bolus", "intravenous", "0.9", "sodium chloride", "NaCl", "following", "next best step", "management", "patient"]}
{"question": "A 38-year-old man is brought to the emergency room by his father because of altered mental status. According to the father, the patient was unable to get out of bed that morning and has become increasingly confused over the past several hours. The father also noticed it was “pretty cold” in his son's apartment because all of the windows were left open overnight. He has a history of hypothyroidism, schizoaffective disorder, type 2 diabetes mellitus, dyslipidemia, and hypertension for which he takes medication. Ten days ago, he was started on a new drug. He appears lethargic. His rectal temperature is 32°C (89.6°F), pulse is 54/min, respirations are 8/min, and blood pressure is 122/80 mm Hg. Examination shows weakness in the lower extremities with absent deep tendon reflexes. Deep tendon reflexes are 1+ in the upper extremities. The pupils are dilated and poorly reactive to light. Throughout the examination, the patient attempts to remove his clothing. Which of the following drugs is the most likely cause of these findings?", "answer": "Fluphenazine", "options": {"A": "Lisinopril", "B": "Fluphenazine", "C": "Levothyroxine", "D": "Atorvastatin\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency room", "father", "altered mental status", "father", "patient", "unable to get out", "bed", "morning", "confused", "past", "hours", "father", "cold", "son's apartment", "windows", "left open overnight", "history of hypothyroidism", "schizoaffective disorder", "type 2 diabetes mellitus", "dyslipidemia", "hypertension", "takes medication", "Ten days", "started", "new drug", "appears lethargic", "rectal temperature", "pulse", "54 min", "respirations", "min", "blood pressure", "80 mm Hg", "Examination shows weakness in", "lower extremities", "absent deep tendon reflexes", "1", "upper extremities", "pupils", "dilated", "poorly reactive to light", "examination", "patient attempts to remove", "clothing", "following drugs", "most likely cause", "findings"]}
{"question": "A 36-year-old woman presents with increased tiredness and lethargy for the past 4 weeks. Investigations show her hemoglobin level to be 8.6 gm/dL and serum creatinine of 4.6 mg/dL. The serum is negative for antinuclear antibodies (ANA) and positive for C3 nephritic factor. Urinalysis shows a 3+ proteinuria. The renal biopsy demonstrates hypercellular glomerulus with electron dense deposits along the glomerular basement membrane. What is the most likely cause?", "answer": "Membrano proliferative glomerulonephritis (MPGN)", "options": {"A": "Membrano proliferative glomerulonephritis (MPGN)", "B": "Rapidly progressive glomerulonephritis (RPGN)", "C": "Minimal change disease", "D": "Membranous glomerulonephritis (MGN)"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["36 year old woman presents", "increased tiredness", "lethargy", "past 4 weeks", "Investigations show", "hemoglobin level to", "8.6 gm dL", "serum creatinine", "mg dL", "serum", "negative", "antinuclear antibodies", "positive", "C3 nephritic factor", "Urinalysis shows", "3", "proteinuria", "renal biopsy demonstrates hypercellular glomerulus", "electron dense deposits", "glomerular basement membrane", "most likely cause"]}
{"question": "A 48-year-old man is brought to the emergency department for sudden onset of difficulty breathing 6 hours ago. For the past several months, he has had shortness of breath on exertion and while lying down on the bed, frequent headaches, and swelling of his feet. He does not take any medications despite being diagnosed with hypertension 10 years ago. His pulse is 90/min, respirations are 20/min, blood pressure is 150/110 mm Hg, and temperature is 37.0°C (98.6°F). Physical examination shows an overweight male in acute distress with audible wheezes. Crackles are heard bilaterally and are loudest at the lung bases. Which of the following findings on cardiac auscultation will most likely be present in this patient?", "answer": "S3 gallop", "options": {"A": "Loud P2", "B": "S3 gallop", "C": "Absent S4", "D": "A loud S1"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old man", "brought", "emergency department", "sudden onset", "difficulty breathing 6 hours", "past", "months", "shortness of breath", "exertion", "lying", "bed", "frequent headaches", "swelling of", "feet", "not take", "medications", "diagnosed", "hypertension 10 years", "pulse", "90 min", "respirations", "20 min", "blood pressure", "mm Hg", "temperature", "98", "Physical examination shows", "overweight male", "acute distress", "wheezes", "Crackles", "heard", "loudest", "lung bases", "following findings", "cardiac auscultation", "most likely", "present", "patient"]}
{"question": "Please refer to the summary above to answer this question\nA medical student is examining the table in the abstract. She notices that the standard error surrounding measurements in the pulmharkimab 150 mg/day group is generally greater than the standard errors for the placebo and pulmharkimab 75 mg/day groups. Which of the following statements is the best explanation for the increased standard error in the pulmharkimab 150 mg/day group?\"\n\"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma\nIntroduction:\nActive asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors. It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease. This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.\nMethods:\nIn this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA. Patients who were immunocompromised or had a history of recurrent infections were excluded.\nPatients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants. All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence. Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms. Plaque volume was determined by ultrasound.\nAnalyses were performed from baseline to month 12.\nResults:\nAt baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all). A total of 215 participants (18%) were lost to follow-up. At 12-month follow-up, the groups contained the following numbers of participants:\nPulmharkimab 75 mg/d: 388 participants\nPulmharkimab 150 mg/d: 202 participants\nPlacebo: 395 participants\nTable 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes. Models were adjusted for sociodemographic variables and medical comorbidities. All outcome variables were approximately normally distributed.\nPulmharkimab 75 mg/d, (Mean +/- 2 SE) Pulmharkimab 150 mg/d, (Mean +/- 2 SE) Placebo, (Mean +/- 2 SE) P-value\nPlaque volume (mm3), change from baseline 6.6 ± 2.8 1.2 ± 4.7 15.8 ± 2.9 < 0.01\nLDL-C levels, change from baseline -9.4 ± 3.6 -11.2 ± 14.3 -8.4 ± 3.9 0.28\nFEV1/FVC ratio, change from baseline 0.29 ± 2.21 0.34 ± 5.54 -0.22 ± 3.21 0.27\nACQ scores, change from baseline 0.31 ± 1.22 0.46 ± 3.25 0.12 ± 1.33 0.43\nConclusion:\nPulmharkimab may be effective in reducing plaque volume but does not lead to improved asthma control in patients with a history of myocardial infarction and comorbid asthma.\nSource of funding: Southeast Institute for Advanced Lung and Cardiovascular Studies, American Center for Advancement of Cardiovascular Health\"", "answer": "It reflects a smaller sample size", "options": {"A": "It indicates decreased external validity", "B": "It indicates a lack of statistical significance", "C": "It reflects a smaller sample size", "D": "It indicates more narrow confidence intervals"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["refer", "summary above to answer", "question", "medical student", "examining", "table", "abstract", "standard error surrounding measurements", "mg/day group", "greater than", "standard errors", "placebo", "75 mg/day groups", "following statements", "best explanation", "increased standard error", "mg/day group", "Impact", "asthma control", "cardiovascular", "patients", "coronary artery disease", "comorbid asthma Introduction", "Active asthma", "found to", "associated with", "two fold increase", "risk", "myocardial infarction", "cardiovascular risk factors", "suggested", "inflammatory mediators", "accelerated atherosclerosis", "systemic inflammation", "increase", "risk", "asthma", "cardiovascular disease", "study evaluated", "efficacy", "novel IL-1 inhibitor", "improving asthma", "cardiovascular", "Methods", "double-blind", "randomized controlled trial", "patients", "N", "history of coronary artery disease", "myocardial infarction", "past", "years", "diagnosis", "comorbid adult-onset asthma", "cardiology clinics", "large academic medical center", "Philadelphia", "PA", "Patients", "immunocompromised", "history", "recurrent infections", "excluded", "Patients", "assigned", "month course", "75 mg/day", "mg/day", "placebo", "group containing 400 participants", "participants", "included", "analysis", "analyzed", "groups", "randomized regardless", "medication adherence", "Variables measured included plaque volume", "serum LDL", "levels", "FEV1/FVC ratio", "Asthma Control Questionnaire", "scores", "quantified", "severity of asthma symptoms", "Plaque volume", "determined by ultrasound", "Analyses", "performed", "baseline", "month", "Results", "baseline", "participants", "two groups", "not", "age", "gender", "race", "plaque volume", "serum LDL", "levels", "FEV1/FVC ratio", "ACQ scores", "p", "0.05", "total", "participants", "lost to follow-up", "month follow-up", "groups contained", "following numbers", "participants", "75 mg/d", "participants", "mg/d", "participants Placebo", "participants Table", "Association", "pulmonary", "cardiovascular outcomes", "Models", "adjusted", "variables", "medical comorbidities", "outcome variables", "approximately", "distributed", "75 mg/d", "Mean", "SE", "mg/d", "Mean", "SE", "Placebo", "Mean", "SE", "P-value Plaque volume", "mm3", "change", "baseline", "0.01", "levels", "change", "baseline", "0", "FEV1/FVC ratio", "change", "baseline 0.29", "54", "27 ACQ scores", "change", "baseline 0.31", "Conclusion", "effective", "reducing plaque volume", "not lead", "improved asthma control", "patients", "history of myocardial infarction", "comorbid asthma", "Source", "funding", "Southeast Institute", "Advanced Lung", "Cardiovascular Studies", "American Center", "Advancement", "Cardiovascular Health"]}
{"question": "A 63-year-old man with diverticular disease comes to the emergency department because of painless rectal bleeding, dizziness, and lightheadedness for 2 hours. His temperature is 37.6°C (99.6°F), pulse is 115/min, respirations are 24/min, and blood pressure is 86/60 mm Hg. He appears pale. Physical examination shows bright red rectal bleeding. Colonoscopy shows profuse diverticular bleeding; endoscopic hemostasis is performed. After initiating fluid resuscitation, the patient becomes hemodynamically stable. The following day, laboratory studies show:\nHemoglobin 8 g/dL\nLeukocyte count 15,500/mm3\nPlatelet count 170,000/mm3\nSerum\nUrea nitrogen 60 mg/dL\nCreatinine 2.1 mg/dL\nBilirubin\nTotal 1.2 mg/dL\nIndirect 0.3 mg/dL\nAlkaline phosphatase 96 U/L\nAlanine aminotransferase (ALT, GPT) 2,674 U/L\nAspartate aminotransferase (AST, GOT) 2,254 U/L\nWhich of the following cells in the patient's liver were most likely damaged first?\"", "answer": "Centrilobular hepatocytes", "options": {"A": "Periportal hepatocytes", "B": "Hepatic sinusoidal endothelial cells", "C": "Hepatic Kupffer cells", "D": "Centrilobular hepatocytes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["63 year old man", "diverticular disease", "emergency department", "painless rectal bleeding", "dizziness", "lightheadedness", "hours", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "appears pale", "Physical examination shows bright red rectal bleeding", "Colonoscopy shows", "diverticular bleeding", "endoscopic hemostasis", "performed", "initiating fluid resuscitation", "patient", "hemodynamically stable", "following day", "laboratory studies show", "Leukocyte count", "mm3 Platelet count", "Serum", "nitrogen", "Indirect 0.3", "96", "L Alanine aminotransferase", "ALT", "GPT", "2", "U/L Aspartate aminotransferase", "AST", "2", "U/L", "following cells", "patient", "iver ", "ost likely  amaged  irst?"]}
{"question": "A 32-year-old man is brought by ambulance to the emergency room after being involved in a head-on motor vehicle collision at high speed. The patient was found unconscious by the paramedics and regained consciousness briefly during the ambulance ride. Upon arrival at the hospital, the patient’s vitals show: pulse 110/min, respiratory rate 12/min, blood pressure 100/70 mm Hg, and oxygen saturation of 96%. Physical examination reveals an unresponsive man with multiple bruises across the chest and along the upper arms with a laceration on the forehead. His is unresponsive to verbal commands and physical touch. His GCS is 6/15. The right pupil is fixed and dilated. An urgent noncontrast CT of the head is performed and shown in the image. The patient is prepared for emergency neurosurgery. Which of the following anesthesia medications would be the best option for this patient?", "answer": "Propofol", "options": {"A": "Propofol", "B": "Midazolam", "C": "Nitrous oxide", "D": "Sevoflurane"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "ambulance", "emergency room", "involved", "head", "motor vehicle collision", "high speed", "patient", "found unconscious", "paramedics", "regained consciousness", "ambulance", "arrival", "hospital", "patients", "show", "pulse", "min", "respiratory rate", "min", "blood pressure 100 70 mm Hg", "oxygen saturation", "96", "Physical examination reveals", "unresponsive man", "multiple bruises", "chest", "upper arms", "laceration", "forehead", "unresponsive", "verbal commands", "physical touch", "GCS", "right pupil", "fixed", "dilated", "urgent", "CT of", "head", "performed", "shown", "image", "patient", "prepared", "emergency neurosurgery", "following anesthesia medications", "best option", "patient"]}
{"question": "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?", "answer": "Inhibits cell wall synthesis", "options": {"A": "Inhibits cell wall synthesis", "B": "Binds D-ala D-ala in the cell wall", "C": "Inhibits initiation complex", "D": "Inhibits sterol synthesis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female presents", "urgent care", "complaints", "one day", "burning", "pain", "urination", "urgency", "frequency", "denies", "fever", "intermittent chills", "sexually active", "uses condoms", "patient", "past medical history", "allergic", "sulfa drugs", "Physical examination of", "genitalia", "normal", "Urinalysis shows positive leukocyte esterase", "nitrites", "urine culture demonstrates gram-negative rods", "form pink colonies", "MacConkey agar", "treated with", "antibiotic", "symptoms", "mechanism", "antibiotic", "most likely treated with", "following"]}
{"question": "A 70-year-old man with a history of hypertension and atrial fibrillation comes to the physician for shortness of breath with mild exertion, progressive weakness, and a dry cough that has persisted for 6 months. He has smoked a pack of cigarettes daily for 45 years. His medications include warfarin, enalapril, and amiodarone. His pulse is 85/min and irregularly irregular. Physical examination shows enlarged fingertips and markedly curved nails. A CT scan of the chest shows clustered air spaces and reticular opacities in the basal parts of the lung. Which of the following is the most likely underlying mechanism of this patient's dyspnea?", "answer": "Excess collagen deposition in the extracellular matrix of the lung", "options": {"A": "Chronic airway inflammation", "B": "Bronchial hyperresponsiveness and obstruction", "C": "Pleural scarring", "D": "Excess collagen deposition in the extracellular matrix of the lung"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old man", "history of hypertension", "atrial fibrillation", "physician", "shortness of breath", "mild exertion", "progressive weakness", "dry cough", "months", "smoked", "pack", "cigarettes daily", "years", "medications include warfarin", "enalapril", "amiodarone", "pulse", "85 min", "irregular", "Physical examination shows enlarged fingertips", "markedly curved nails", "CT scan of", "chest shows clustered air spaces", "reticular opacities", "basal parts of", "lung", "following", "most likely underlying mechanism", "patient's dyspnea"]}
{"question": "A 21-year-old man is brought to the emergency department by his mother after being found lying unconscious next to a bottle of pills. The patient’s mother mentions that he has been diagnosed with major depressive disorder 3 years ago for which he was taking a medication that resulted in only a slight improvement in his symptoms. She says he still found it difficult to concentrate on his studies and did not participate in any social events in college. He didn’t have many friends and was often found sitting alone in his room. He has also threatened to take his life on several occasions, but she did not think he was serious. While recording his vital signs, the patient goes into a coma. His ECG shows a QT interval of 450 milliseconds. Which of the following medications did this patient most likely overdose on?", "answer": "Clomipramine", "options": {"A": "Bupropion", "B": "Sertraline", "C": "Venlafaxine", "D": "Clomipramine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["21-year-old man", "brought", "emergency department", "mother", "found lying unconscious next to", "bottle", "pills", "patients mother", "diagnosed", "major depressive disorder", "years", "taking", "medication", "resulted", "only", "slight improvement", "symptoms", "found", "difficult to concentrate", "studies", "not", "social events", "college", "friends", "often found sitting alone", "room", "to take", "life", "occasions", "not think", "serious", "recording", "vital signs", "patient goes", "coma", "ECG shows", "QT interval", "450 milliseconds", "following medications", "patient", "likely overdose"]}
{"question": "In a study to determine the risk factors for myocardial infarction (MI) at a young age (age < 30 years), 30 young patients with the condition are recruited into the study group. Sixty similar but healthy individuals are recruited into the control group. Educational status is considered to be an important variable, as it would affect the awareness of the disease and its risk factors among the participants. Based on the level of education, 2 groups are formed: low educational status and high educational status. A chi-square test is performed to test the significance of the relationship, and an odds ratio of 2.1 was computed for the association between low education and the risk of MI, with a confidence interval of 0.9–9.7. What inference can be made on the association between young age MI and educational status from this study?", "answer": "The association is not statistically significant, and low education is not a risk factor.", "options": {"A": "The association is not statistically significant, and low education is not a risk factor.", "B": "The association is statistically significant, but low education is not a risk factor.", "C": "The association is not statistically significant, but low education is a risk factor.", "D": "One can not comment, as the p-value is not given."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["study to", "risk factors", "myocardial infarction", "young age", "age", "30 years", "30 young patients", "condition", "study group", "Sixty similar", "healthy individuals", "control group", "Educational status", "considered to", "important variable", "affect", "awareness", "disease", "risk factors", "participants", "Based", "level of education", "2 groups", "formed", "low educational status", "high educational status", "chi-square test", "performed to test", "significance", "relationship", "odds ratio", "computed", "association", "low education", "risk", "MI", "confidence interval", "0.99", "inference", "made", "association", "young age MI", "educational status", "study"]}
{"question": "A 32-year-old primigravid woman at 16 weeks' gestation comes to the physician for a routine prenatal visit. She is asymptomatic and has no history of serious illness. Her only medication is a prenatal vitamin. Her temperature is 37.2°C (99°F) and blood pressure is 108/60 mm Hg. Pelvic examination shows a uterus consistent in size with a 16-week gestation. A quadruple screening test shows maternal serum AFP of 3 times the median and normal levels of serum β-hCG, estriol, and inhibin A. Which of the following is most likely to account for these findings?", "answer": "Neural tube defect", "options": {"A": "Partial molar pregnancy", "B": "Neural tube defect", "C": "Trisomy 18", "D": "Trisomy 21"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old primigravid woman", "weeks", "gestation", "physician", "routine prenatal visit", "asymptomatic", "history", "serious illness", "only medication", "prenatal vitamin", "temperature", "blood pressure", "60 mm Hg", "Pelvic examination shows", "uterus consistent", "size", "week gestation", "quadruple screening test shows maternal serum", "times", "median", "normal levels", "serum", "hCG", "estriol", "inhibin A", "following", "most likely to account", "findings"]}
{"question": "A 39-year-old man presents to the emergency department complaining of a sharp pain that radiates along his right hemithorax, which worsens with deep inspiration. He says this started abruptly about 6 hours ago. He says that he has not noticed that anything that makes his pain better or worse. He also denies any other symptoms. He works as a long-haul truck driver, and he informs you that he recently returned to the east coast from a trip to Utah. His medical history is significant for gout, hypertension, hypercholesterolemia, diabetes mellitus type 2, and acute lymphoblastic leukemia from when he was a child. He currently smokes 2 packs of cigarettes/day, drinks a 6-pack of beer/day, and he denies any illicit drug use. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 98/min, and respiratory rate 23/min. His physical examination shows minimal bibasilar rales, but otherwise clear lungs on auscultation, normal heart sounds, and a benign abdominal physical examination. Which of the following is the most reasonable 1st step towards ruling out the diagnosis of pulmonary embolism in a low-risk patient?", "answer": "D-dimer", "options": {"A": "ECG", "B": "V/Q scan", "C": "D-dimer", "D": "CT pulmonary angiogram with IV contrast"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency department complaining of a sharp pain", "radiates", "right hemithorax", "worsens", "deep inspiration", "started", "hours", "not", "makes", "pain better", "worse", "denies", "symptoms", "works", "long", "truck driver", "informs", "recently returned", "east", "trip", "Utah", "medical history", "significant", "gout", "hypertension", "hypercholesterolemia", "diabetes mellitus type 2", "acute lymphoblastic leukemia", "child", "currently smokes 2 packs", "cigarettes day", "drinks", "pack", "beer day", "denies", "illicit drug use", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 98 min", "respiratory rate 23 min", "physical examination shows minimal", "rales", "clear lungs", "auscultation", "normal heart sounds", "benign abdominal physical examination", "following", "most", "1st step", "ruling out", "diagnosis", "pulmonary embolism", "low-risk patient"]}
{"question": "A 47-year-old woman presents to her primary care physician for evaluation of her right hand. Specifically, she says that she was gardening 8 hours prior to presentation when she sustained a laceration over her distal interphalangeal (DIP) joints. Since then, they have become red and swollen. She has also had pain in her proximal interphalangeal (PIP) joints and metacarpophalangeal (MCP) joints for several years and reports that this pain is worse in the morning but improves over the day. The cells that are present in this patient's DIP joints and PIP joints are analyzed and compared. Which of the following is most likely to be true about this patient's findings?", "answer": "DIP has more neutrophils and fewer monocytes than PIP", "options": {"A": "DIP has fewer neutrophils and more monocytes than PIP", "B": "DIP has more neutrophils and fewer monocytes than PIP", "C": "DIP has more neutrophils and more monocytes than PIP", "D": "DIP and PIP have similar numbers of neutrophils and monocytes"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "evaluation", "right hand", "gardening 8 hours prior to presentation", "sustained", "laceration", "distal interphalangeal", "joints", "then", "red", "swollen", "pain", "proximal interphalangeal", "joints", "metacarpophalangeal", "joints", "years", "reports", "pain", "worse", "morning", "improves", "day", "cells", "present", "patient's DIP joints", "PIP joints", "analyzed", "compared", "following", "most likely to", "true", "patient's findings"]}
{"question": "A 24-year-old woman presents to the emergency department with a severe headache. She states it is 10/10 in intensity and states that it is associated with chewing. She describes it as a dull pain over the sides of her head. The patient is otherwise healthy and is not currently taking any medications. Her temperature is 97.0°F (36.4°C), blood pressure is 111/74 mmHg, pulse is 83/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for pain and tenderness over the mandibular and temporal region that is worsened when the patient opens and closes their mouth. Which of the following is the most likely diagnosis?", "answer": "Temporomandibular joint dysfunction", "options": {"A": "Migraine headache", "B": "Temporal arteritis", "C": "Temporomandibular joint dysfunction", "D": "Tension headache"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "emergency department", "severe headache", "states", "10", "intensity", "states", "associated with chewing", "dull pain", "sides of", "head", "patient", "healthy", "not currently taking", "medications", "temperature", "97", "36 4C", "blood pressure", "74 mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "pain", "tenderness", "mandibular", "temporal region", "worsened", "patient opens", "closes", "mouth", "following", "most likely diagnosis"]}
{"question": "Twelve hours after undergoing an exploratory laparotomy for a perforated duodenal ulcer, a 36-year-old man has shortness of breath. He has asthma well controlled with an albuterol inhaler. His father died of lung cancer at 62 years of age. He has smoked one pack of cigarettes daily for 14 years. He does not drink alcohol. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 98/min, respirations are 19/min, and blood pressure is 122/76 mm Hg. Examination shows reduced breath sounds over the left lung base. Cardiac examination shows no abnormalities. There is a clean, dry surgical incision over the midline of the abdomen. Bowel sounds are hypoactive. The calves are soft and nontender. His hemoglobin concentration is 12.9 g/dL, leukocyte count is 10,600/mm3, and platelet count is 230,000/mm3. An x-ray of the chest in supine position is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Atelectasis", "options": {"A": "Asthma exacerbation", "B": "Pneumonitis", "C": "Pulmonary embolism", "D": "Atelectasis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Twelve hours", "exploratory laparotomy", "perforated duodenal ulcer", "36 year old man", "shortness of breath", "asthma well controlled", "albuterol inhaler", "father died of lung cancer", "62 years", "age", "smoked one pack", "cigarettes daily", "years", "not drink alcohol", "appears", "temperature", "4C", "99", "pulse", "98 min", "respirations", "min", "blood pressure", "76 mm Hg", "Examination shows reduced breath sounds", "left lung base", "Cardiac examination shows", "abnormalities", "clean", "dry surgical incision", "midline of", "abdomen", "Bowel sounds", "hypoactive", "calves", "soft", "nontender", "hemoglobin concentration", "g/dL", "leukocyte count", "10 600 mm3", "platelet count", "mm3", "x-ray of", "chest", "supine position", "shown", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 62-year-old man is brought to the emergency department 40 minutes after his wife noticed during breakfast that the left side of his face was drooping. He had difficulty putting on his shirt and shoes before coming to the hospital. He has type 2 diabetes mellitus, hypertension, and hypercholesterolemia. His current medications include metformin, enalapril, and atorvastatin. He has smoked one pack of cigarettes daily for 35 years. He drinks one glass of wine daily. He is alert and oriented to time, place and person. His temperature is 37°C (98.6°F), pulse is 99/min and blood pressure is 170/100 mm Hg. Examination shows equal and reactive pupils. There is drooping of the left side of the face. Muscle strength is decreased in the left upper and lower extremities. Plantar reflex shows an extensor response on the left side. Speech is dysarthric. There is a bruit on the right side of the neck. Fundoscopy shows no abnormalities. A complete blood count, coagulation profile, and serum concentrations of glucose and electrolytes are within the reference range. Which of the following is the most appropriate next step in management?", "answer": "CT scan of the head", "options": {"A": "MRI of the brain", "B": "Lumbar puncture", "C": "Duplex ultrasonography of the neck", "D": "CT scan of the head"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man", "brought", "emergency department 40 minutes", "wife", "breakfast", "left side of", "face", "difficulty putting", "shirt", "shoes", "hospital", "type 2 diabetes mellitus", "hypertension", "hypercholesterolemia", "current medications include metformin", "enalapril", "atorvastatin", "smoked one pack", "cigarettes daily", "35 years", "drinks one glass", "wine daily", "alert", "oriented to time", "place", "person", "temperature", "98", "pulse", "99 min", "blood pressure", "100 mm Hg", "Examination shows equal", "reactive pupils", "of", "left side", "face", "Muscle strength", "decreased", "left upper", "lower extremities", "Plantar reflex shows", "extensor response", "left side", "Speech", "bruit", "right side of", "neck", "Fundoscopy shows", "abnormalities", "complete blood count", "coagulation profile", "serum", "glucose", "electrolytes", "reference range", "following", "most appropriate next step", "management"]}
{"question": "A 24-year-old man, who recently migrated from a developing country, presents to a physician because of a 2-year history of cough, blood in his sputum, fever, and weight loss. His sputum smear and culture confirm the diagnosis of pulmonary tuberculosis due to Mycobacterium tuberculosis. His Mantoux test is 2 mm × 3 mm, and his chest radiograph is normal. High-sensitivity enzyme-linked immunosorbent assay for HIV-1 and Western blot assay for HIV-1 are positive. His CD4+ T cell count is 90/μL and HIV RNA is 30,000 copies/mL. He is started on a 4-drug regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol in appropriate doses. He becomes sputum smear-negative after 4 weeks and reports significant improvement in symptoms. After another 4 weeks, the physician removes pyrazinamide from the antitubercular regimen and adds antiretroviral therapy (dolutegravir/tenofovir/emtricitabine). After 3 weeks, the patient presents with complaints of fever and significantly increased cough for 3 days. There is no respiratory distress but generalized lymphadenopathy is present. His chest radiograph shows pulmonary infiltrates and mediastinal lymphadenopathy, sputum smear is negative, Mantoux test is 12 mm × 14 mm, CD4+ T cell count is 370/μL, and HIV RNA is 2,900 copies/mL. What is the most appropriate initial step in treatment?", "answer": "Continue antitubercular therapy and antiretroviral therapy without any change", "options": {"A": "Stop antiretroviral therapy and continue antitubercular therapy", "B": "Change antitubercular therapy to isoniazid-rifampin-pyrazinamide-ethambutol-streptomycin", "C": "Change antitubercular therapy to isoniazid-rifampin-ethambutol-streptomycin", "D": "Continue antitubercular therapy and antiretroviral therapy without any change"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "recently migrated", "developing country", "presents", "physician", "2 year history", "cough", "blood", "sputum", "fever", "weight loss", "sputum smear", "culture confirm", "diagnosis", "pulmonary tuberculosis", "Mycobacterium tuberculosis", "Mantoux test", "2 mm", "chest radiograph", "High-sensitivity enzyme-linked immunosorbent assay", "HIV-1", "Western blot assay", "HIV-1", "positive", "CD4", "cell count", "90", "HIV RNA", "30", "copies/mL", "started", "drug regimen consisting", "isoniazid", "rifampin", "pyrazinamide", "ethambutol", "appropriate doses", "sputum smear negative", "weeks", "reports significant improvement", "symptoms", "4 weeks", "physician removes pyrazinamide", "antitubercular regimen", "adds antiretroviral therapy", "dolutegravir tenofovir emtricitabine", "3 weeks", "patient presents", "complaints", "fever", "increased cough", "3 days", "respiratory distress", "generalized lymphadenopathy", "present", "chest radiograph shows pulmonary infiltrates", "mediastinal lymphadenopathy", "sputum smear", "negative", "Mantoux test", "mm", "CD4", "cell count", "370", "HIV RNA", "2 900 copies/mL", "most appropriate initial step", "treatment"]}
{"question": "A 6-year-old boy presents with fever, malaise, and intense pain in the anterior neck. His vital signs include: body temperature 39.0°C (102.2°F), heart rate 120/min, and respiratory rate 18/min and regular. On physical examination, there is erythema, tenderness and enlargement of the thyroid gland that is worse on the left. Pain is worsened during neck hyperextension and relieved during neck flexion. Thyroid function tests are within normal limits. An ultrasound of the thyroid gland reveals a unifocal perithyroidal hypoechoic space. Which of the following is the most likely mechanism underlying this patient’s condition?", "answer": "Pyriform sinus fistula", "options": {"A": "Postviral inflammatory process", "B": "Pyriform sinus fistula", "C": "Antithyroid peroxidase (TPO)", "D": "Autoantibodies to the thyrotropin receptor (TRAb)"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "fever", "malaise", "intense pain in", "anterior neck", "vital signs include", "body temperature", "heart rate", "min", "respiratory rate", "min", "regular", "physical examination", "erythema", "tenderness", "enlargement of", "thyroid gland", "worse", "left", "Pain", "worsened", "neck hyperextension", "relieved", "neck flexion", "Thyroid function tests", "normal limits", "ultrasound", "thyroid reveals", "unifocal", "space", "following", "most likely mechanism", "patients condition"]}
{"question": "A 65-year-old previously healthy man presents to the primary care physician with the chief complaint of red colored urine over the past month. He states that he does not experience dysuria. On physical exam there is no costovertebral angle tenderness. With this presentation which is the most likely cause of this patient's hematuria?", "answer": "Bladder tumor", "options": {"A": "Bladder tumor", "B": "Renal cell carcinoma", "C": "Beeturia", "D": "Urinary tract infection"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["65 year old", "healthy man presents", "primary care physician", "chief complaint of red colored urine", "past month", "states", "not experience dysuria", "physical exam", "costovertebral angle tenderness", "presentation", "most likely cause", "patient's hematuria"]}
{"question": "A 13-year-old boy is brought to the emergency room by his mother with confusion, abdominal pain, and vomiting for the previous day. The patient’s mother says he started complaining of pain in his abdomen after he got back from school yesterday and vomited 3 times during the night. This morning, he seemed confused so she rushed him to the ER. She has also noticed that he has been urinating frequently and drinking a lot of water recently, and he has lost 6 kg (13.2 lb) over the past 20 days. His vital signs include: blood pressure 100/50 mm Hg, heart rate 110/min, respiratory rate 27/min, and temperature 35.6°C (96.0°F). His BMI is 18 kg/m2. On physical examination, he is disoriented to time and place and is taking deep and labored breaths. There is diffuse tenderness to palpation in the abdomen with guarding. Laboratory tests are significant for a pH of 7.19 and a blood glucose level of 754 mg/dL. The doctor explains to his mother that her son has developed a life-threatening complication of a disease characterized by decreased levels of a hormone. Which of the following would you most likely expect to see in this patient?", "answer": "Decreased glucose uptake by adipocytes", "options": {"A": "Decreased glucose uptake by adipocytes", "B": "Decreased activity of hormone sensitive lipase", "C": "Decreased proteolysis", "D": "Increased lipoprotein lipase activity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency room", "mother", "confusion", "abdominal pain", "vomiting", "previous day", "patients mother", "started", "pain", "abdomen", "got back", "school", "vomited 3", "night", "morning", "confused", "rushed", "ER", "frequently", "drinking", "lot", "water recently", "lost", "kg", "past 20 days", "vital signs include", "blood pressure 100 50 mm Hg", "heart rate", "min", "respiratory rate 27 min", "temperature 35", "96", "BMI", "kg/m2", "physical examination", "disoriented", "time", "place", "taking deep", "labored breaths", "diffuse tenderness", "palpation", "abdomen", "guarding", "Laboratory tests", "significant", "pH", "7", "blood glucose level", "mg/dL", "doctor", "mother", "son", "life-threatening complication of", "disease characterized", "decreased levels", "hormone", "following", "most likely", "to see", "patient"]}
{"question": "A 58-year-old woman presents to the emergency department because of worsening abdominal pain for the past 2 days. She reports nausea and vomiting and is unable to tolerate oral intake. She appears uncomfortable. Her temperature is 38.1°C (100.6°F), the pulse is 92/min, the respirations are 18/min, and the blood pressure is 132/85 mm Hg. Physical examination shows yellowish discoloration of her sclera. Her abdomen is tender in the right upper quadrant. There is no abdominal distention or organomegaly. The laboratory tests show the following results:\nHemoglobin 13 g/dL\nLeukocyte count 16,000/mm3\nUrea nitrogen 25 mg/dL\nCreatinine 2 mg/dL\nAlkaline phosphatase 432 U/L\nAlanine aminotransferase 196 U/L\nAspartate transaminase 207 U/L\nBilirubin  \nTotal 3.8 mg/dL\nDirect 2.7 mg/dL\nLipase 82 U/L\nUltrasound of the right upper quadrant shows dilated intrahepatic and extrahepatic bile ducts and multiple hyperechoic spheres within the gallbladder. The pancreas is not well visualized. Intravenous fluid resuscitation and antibiotic therapy with ceftriaxone and metronidazole are initiated. After 12 hours, the patient appears acutely ill and is not oriented to time. Her temperature is 39.1°C (102.4°F), the pulse is 105/min, the respirations are 22/min, and the blood pressure is 112/82 mm Hg. Which of the following is the most appropriate next step in management?", "answer": "Endoscopic retrograde cholangiopancreatography (ERCP)", "options": {"A": "Endoscopic retrograde cholangiopancreatography (ERCP)", "B": "Laparoscopic cholecystectomy", "C": "Magnetic resonance cholangiopancreatography (MRCP)", "D": "Percutaneous cholecystostomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old woman presents", "emergency department", "of worsening abdominal", "past 2 days", "reports nausea", "vomiting", "unable to", "oral intake", "appears", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "85 mm Hg", "Physical examination shows", "discoloration", "sclera", "abdomen", "tender", "right upper quadrant", "abdominal distention", "organomegaly", "laboratory tests show", "following results", "Hemoglobin", "Leukocyte 16", "mm3", "nitrogen", "L Alanine", "transaminase", "Total", "Direct 2.7 mg Lipase", "U Ultrasound", "right upper quadrant shows dilated intrahepatic", "extrahepatic bile ducts", "multiple hyperechoic spheres", "gallbladder", "pancreas", "not well visualized", "Intravenous", "antibiotic therapy", "ceftriaxone", "metronidazole", "initiated", "12 hours", "patient appears", "ill", "not oriented to time", "temperature", "4F", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "following", "most appropriate next step", "management"]}
{"question": "A 62-year-old man presents to his primary care doctor with continued hypertension despite adherence to multiple anti-hypertensive medications. The physician suspects that the patient may have elevated aldosterone levels and wants to initiate a trial of an aldosterone receptor antagonist. The patient is very concerned about side effects, particularly impotence and gynecomastia, as he had a friend who took a similar medication and had these side-effects. Which of the following is the best medication to initiate, given his concerns and the physician's diagnosis?", "answer": "Eplerenone", "options": {"A": "Spironolactone", "B": "Eplerenone", "C": "Triamterene", "D": "Ethacrynic acid"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old man presents", "primary care doctor", "continued hypertension", "adherence", "multiple anti-hypertensive medications", "physician suspects", "patient", "elevated aldosterone levels", "to initiate", "trial", "aldosterone receptor antagonist", "patient", "very concerned", "side effects", "impotence", "gynecomastia", "friend", "took", "similar medication", "side-effects", "following", "best medication to initiate", "given", "concerns", "physician's diagnosis"]}
{"question": "A 30-year-old woman presents to the emergency department with a recent episode of chest pain. She says she was previously well and denies any history of similar symptoms. She reports that, at onset, she felt as if she was going to die and says her heart beating has been beating really fast. There was also profuse sweating, and she says she feels short of breath. She could not recall how long the event lasted but can remember that the symptoms did go away on their own by the time she arrived at the emergency department. Her vitals rapidly returned to normal while giving her medical history and she begins to look and act more calm. No significant past medical history or current medications.  Physical examination is unremarkable. Her electrocardiogram and initial cardiac enzymes are normal. Which the following is necessary to confirm the most likely diagnosis in this patient?", "answer": "1 month of associated symptoms ", "options": {"A": "1 month of associated symptoms ", "B": "Disruptive events lasting > 30 minutes on 2 separate occasions", "C": "Family history", "D": "Agoraphobia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "emergency department", "recent episode of chest pain", "well", "denies", "history", "similar symptoms", "reports", "onset", "felt", "to die", "heart beating", "beating", "fast", "profuse sweating", "feels short of breath", "not recall", "long", "event lasted", "remember", "symptoms", "go", "time", "arrived", "emergency department", "rapidly returned", "normal", "giving", "medical history", "begins to look", "act more calm", "significant past medical history", "current medications", "Physical examination", "unremarkable", "electrocardiogram", "initial cardiac enzymes", "normal", "following", "to confirm", "most likely diagnosis", "patient"]}
{"question": "A previously healthy 14-year-old boy is brought to the physician for evaluation because of loss of appetite, sleeplessness, and extreme irritability for the past 3 weeks. He was recently kicked off of the school's football team after missing too many practices. He has also been avoiding his family and friends because he is not in the mood to see them, but he admits that he is lonely. He has not left his room for 2 days, which prompted his father to bring him to the physician. He has no medical conditions and does not take any medications. He does not drink alcohol or use recreational drugs. While the father is in the waiting room, a mental status examination is conducted, which shows a constricted affect. Cognition is intact. He says that he would be better off dead and refuses to be treated. He says he wants to use his father's licensed firearm to “end his misery” over the weekend when his parents are at church. Which of the following is the most appropriate next step in management?", "answer": "Involuntary hospitalization after informing the parents", "options": {"A": "Agree to his wish for no further treatment", "B": "Involuntary hospitalization after informing the parents", "C": "Reassure the patient that he will feel better", "D": "Start outpatient psychotherapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "evaluation", "of loss", "appetite", "sleeplessness", "extreme irritability", "past", "weeks", "recently", "school's football team", "missing", "practices", "family", "friends", "not", "mood to see", "admits", "lonely", "not left", "room", "2 days", "prompted", "father to", "physician", "medical conditions", "not take", "medications", "not drink alcohol", "use recreational drugs", "father", "waiting room", "mental", "conducted", "shows", "constricted affect", "Cognition", "intact", "better", "dead", "refuses to", "treated", "to use", "father's licensed firearm to end", "misery", "weekend", "parents", "church", "following", "most appropriate next step", "management"]}
{"question": "A previously healthy 6-year-old boy is brought to the physician because of generalized malaise and a palpable swelling in the left axilla. The parents report that 2 weeks ago, his daycare group visited an animal shelter, after which he developed a rash on the left hand. His temperature is 38.5°C (101.3°F). Physical examination shows three linear crusts on an erythematous background on the dorsum of the left hand. There is tender left-sided axillary and cervical lymphadenopathy. Histopathologic examination of an axillary lymph node shows necrotizing granulomas. The most likely causal organism of this patient's clinical findings is also involved in the pathogenesis of which of the following conditions?", "answer": "Bacillary angiomatosis", "options": {"A": "Bacillary angiomatosis", "B": "Condylomata lata", "C": "Brucellosis", "D": "Bubonic plague"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "generalized malaise", "palpable swelling", "left axilla", "parents report", "2 weeks", "daycare group visited", "animal shelter", "rash", "left", "temperature", "Physical examination shows three linear crusts", "erythematous background", "dorsum of", "left hand", "tender left-sided axillary", "cervical", "Histopathologic examination", "axillary shows necrotizing granulomas", "most likely causal organism", "patient's clinical findings", "involved", "pathogenesis", "following conditions"]}
{"question": "A 56-year-old man is brought to the emergency department with severe dyspnea and a productive cough containing streaks of blood since the day before. He had a sudden pruritic papular rash on his right thigh when he was in the southwestern USA hiking in northern Arizona and New Mexico. The next day he developed severely painful inguinal swelling on the same side; however, he did not see a physician and controlled the pain with painkillers. There is no other history of serious illness. He does not take any other medications. He appears confused. The temperature is 39.5℃ (103.1℉), the pulse is 105/min, the respiration rate is 32/min, and the blood pressure is 95/45 mm Hg. Rales are heard in the lower lobe of the left lung on auscultation. The right inguinal lymph nodes are enlarged with a spongy consistency and an underlying hard core. The surrounding area is edematous without overlying erythema or cellulitis. A computerized tomography (CT) scan is shown in the picture. Which of the following best explains these findings?", "answer": "Plague", "options": {"A": "Lyme disease", "B": "Malaria", "C": "Plague", "D": "Legionnaire's disease"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "severe dyspnea", "productive cough containing streaks of blood", "day", "sudden pruritic papular rash", "right thigh", "southwestern USA hiking", "northern Arizona", "New Mexico", "next day", "severely painful inguinal swelling", "same side", "not see", "physician", "controlled", "pain", "painkillers", "history", "serious illness", "not take", "medications", "appears confused", "temperature", "pulse", "min", "respiration rate", "min", "blood pressure", "95", "mm Hg", "Rales", "heard", "the lower lobe of", "left lung", "auscultation", "right inguinal lymph nodes", "enlarged with", "spongy consistency", "underlying hard core", "surrounding area", "edematous", "erythema", "cellulitis", "computerized tomography", "scan", "shown", "picture", "following best", "findings"]}
{"question": "A 44-year-old man presents to the family medicine clinic for some small bumps on his left thigh. The lesions are non-pruritic and have been present for the last 3 weeks. He reports feeling fatigued and malaise for the past few months. The patient has no known medical problems and takes no medications. He smokes one pack of cigarettes per day and uses intravenous street drugs. His heart rate is 82/min, the respiratory rate is 14/min, the temperature is 36.7°C (98.1°F), and the blood pressure is 126/80 mm Hg. Auscultation of the heart is without murmurs. Lungs are clear to auscultation bilaterally. Three 2-3 mm, dome-shaped, hardened papules are noted on the left thigh. Central umbilication can be observed in each papule. There is a non-tender cervical lymphadenopathy present. Which of the following is the most likely diagnosis?", "answer": "Molluscum contagiosum", "options": {"A": "Bed bug bite", "B": "Molluscum contagiosum", "C": "Atopic dermatitis", "D": "Acute urticaria"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "family medicine clinic", "small", "left thigh", "lesions", "non-pruritic", "present", "weeks", "reports feeling fatigued", "malaise", "past", "months", "patient", "known medical problems", "takes", "medications", "smokes one pack", "cigarettes", "day", "uses intravenous street drugs", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "blood pressure", "80 mm Hg", "Auscultation of", "heart", "murmurs", "Lungs", "clear", "auscultation", "Three", "mm", "dome-shaped", "hardened papules", "noted", "left thigh", "Central", "observed", "papule", "non-tender cervical lymphadenopathy present", "following", "most likely diagnosis"]}
{"question": "A prominent male politician has secret homosexual desires. However, rather than engaging in homosexual behavior, he holds rallies against gay rights and regularly criticizes gay people. The politician is displaying which of the following defense mechanisms?", "answer": "Reaction formation", "options": {"A": "Repression", "B": "Reaction formation", "C": "Denial", "D": "Displacement"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["prominent male politician", "secret homosexual desires", "engaging", "homosexual behavior", "holds", "gay rights", "gay people", "politician", "displaying", "following defense mechanisms"]}
{"question": "A 55-year-old man presents to his primary care physician for a general checkup. The patient has a past medical history of diabetes, hypertension, and atrial fibrillation and is currently taking warfarin, insulin, lisinopril, and metoprolol. The patient’s brother recently died from a heart attack and he has switched to an all vegetarian diet in order to improve his health. His temperature is 98.6°F (37.0°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. The patient’s physical exam is unremarkable. His laboratory values are ordered as seen below.\n\nHemoglobin: 12 g/dL\nHematocrit: 36%\nLeukocyte count: 7,550/mm^3 with normal differential\nPlatelet count: 197,000/mm^3\nINR: 1.0\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\n\nWhich of the following is the best explanation for this patient’s laboratory values?", "answer": "Dietary changes", "options": {"A": "Dietary changes", "B": "Increased hepatic metabolism", "C": "Increased renal clearance", "D": "Medication noncompliance"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man presents", "primary care physician", "general checkup", "patient", "past medical diabetes", "hypertension", "atrial fibrillation", "currently taking warfarin", "insulin", "lisinopril", "metoprolol", "patients brother recently died", "heart attack", "switched", "vegetarian diet", "order to", "health", "temperature", "98", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "patients physical exam", "unremarkable", "laboratory values", "ordered", "seen", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "7 550 mm", "normal differential Platelet count", "mm", "INR", "1 0", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL", "following", "best explanation", "patients laboratory values"]}
{"question": "A 20-year-old woman in the army recruit collapses during an especially hot day at basic training. She was in her normal excellent state of health prior to this event. Two weeks ago, she had an upper respiratory infection (URI) but has since recovered. Her father has chronic kidney disease (CKD), bilateral hearing loss, and vision problems. At the hospital, her temperature is 40.3°C (104.5°F), blood pressure is 85/55 mm Hg, pulse is 105/min, and respiratory rate is 24/min. On physical exam, the patient appears to have altered mental status and her skin is dry, hot, and erythematous. She is complaining of severe bilateral flank pain and generalized myalgia. Catheterization produces 200 mL of tea-colored urine. Urine dipstick is positive for blood, but urinalysis is negative for RBCs or WBCs. Which of the following is most likely responsible for her condition?", "answer": "Heat stroke", "options": {"A": "A mutation of the COL4A5 gene", "B": "Neisseria meningitides", "C": "Heat stroke", "D": "IgA nephropathy"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["20 year old woman", "army", "collapses", "hot day", "basic training", "normal excellent state of health", "event", "Two weeks", "upper respiratory infection", "since recovered", "father", "chronic kidney disease", "bilateral hearing loss", "vision problems", "hospital", "temperature", "40 3C", "blood pressure", "85 55 mm Hg", "pulse", "min", "respiratory rate", "min", "physical exam", "patient appears to", "altered mental status", "skin", "dry", "hot", "erythematous", "severe bilateral flank", "generalized myalgia", "Catheterization", "200 mL of tea colored urine", "dipstick", "positive", "blood", "urinalysis", "negative", "RBCs", "WBCs", "following", "most likely responsible", "condition"]}
{"question": "A 60-year-old man with a long-standing history of chronic hepatitis C infection comes to the emergency department because of abdominal distention and scleral icterus for the past month. His heart rate is 76/min, respiratory rate is 14/min, temperature is 36.0°C (96.8°F), and blood pressure is 110/86 mm Hg. Physical examination show signs suggestive of liver cirrhosis. Which of the following signs is a direct result of hyperestrinism in cirrhotic patients?", "answer": "Gynecomastia", "options": {"A": "Coagulopathy", "B": "Gynecomastia", "C": "Jaundice", "D": "Caput medusae"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year", "man", "long standing history of chronic hepatitis C infection", "emergency department", "abdominal distention", "scleral icterus", "past month", "heart rate", "76 min", "respiratory rate", "min", "temperature", "36", "96", "blood pressure", "mm Hg", "Physical examination show signs suggestive of liver cirrhosis", "following signs", "direct result", "cirrhotic patients"]}
{"question": "A 47-year-old woman seeks evaluation at your office because she has had postcoital vaginal bleeding for the past 8 months with occasional intermenstrual watery, blood-tinged vaginal discharge. Her family history is negative for malignancies and inherited disorders. She is the result of a pregnancy complicated by numerous miscarriages in the 1960s, for which her mother received diethylstilbestrol. During a pelvic examination, you notice a polypoid mass on the anterior wall of the vagina. The bimanual examination is negative for adnexal masses. You suspect the presence of carcinoma and, therefore, send tissue samples to pathology, which confirmed the presence of malignant cells. Which of the following is the most likely malignant tumor in this patient?", "answer": "Clear cell adenocarcinoma", "options": {"A": "Clear cell adenocarcinoma", "B": "Melanoma", "C": "Botryoid sarcoma", "D": "Verrucous carcinoma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "evaluation", "office", "postcoital vaginal bleeding", "past", "months", "occasional", "watery", "blood-tinged vaginal discharge", "family history", "negative", "malignancies", "inherited disorders", "result", "pregnancy complicated", "numerous miscarriages", "1960s", "mother received diethylstilbestrol", "pelvic examination", "polypoid mass", "anterior wall of", "vagina", "bimanual examination", "negative", "adnexal masses", "suspect", "presence", "carcinoma", "send tissue samples", "pathology", "confirmed", "presence of malignant cells", "following", "most likely malignant tumor", "patient"]}
{"question": "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?", "answer": "Lowering citalopram dose", "options": {"A": "Lowering citalopram dose", "B": "Addition of bupropion", "C": "Switch to fluoxetine", "D": "Switch to selegiline"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old man visits", "office", "annual health", "diagnosed", "generalized anxiety disorder", "months", "treated with citalopram", "comments", "symptoms", "improved since initiating", "prescribed therapy", "past", "months", "unable to", "sexual intercourse due to weak tumescence", "low libido", "blood pressure", "74 mm Hg", "heart rate", "75 min", "respiratory rate", "min", "Physical examination reveals regular heart", "lung sounds", "appropriate step", "management", "patient"]}
{"question": "A 63-year-old man comes to the physician for the evaluation of an unintentional 10-kg (22-lb) weight loss over the past 6 months. During this period, the patient has had recurrent episodes of high-grade fever, night sweats, and feelings of fatigue. Two months ago, he had herpes zoster that was treated with acyclovir. He appears pale. Temperature is 38.5°C (101.3°F), pulse is 90/min, and blood pressure 130/80 mm Hg. Physical examination shows generalized painless lymphadenopathy. The liver and the spleen are palpated 2–3 cm below the right and the left costal margin, respectively. Laboratory studies show:\nHematocrit 42%\nLeukocyte count 15,000/mm3\nSegmented neutrophils 46%\nEosinophils 1%\nLymphocytes 50%\nMonocytes 3%\nPlatelet count 120,000/mm3\nBlood smear shows mature lymphocytes that rupture easily and appear as artifacts on a blood smear. Flow cytometry shows lymphocytes expressing CD5, CD19, CD20, and CD23. Which of the following is the most appropriate treatment?\"", "answer": "Fludarabine, cyclophosphamide, rituximab", "options": {"A": "All-trans retinoic acid", "B": "Fludarabine, cyclophosphamide, rituximab", "C": "Observation and disease progression monitoring", "D": "Imatinib only\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old man", "physician", "evaluation", "unintentional 10 kg", "weight loss", "past 6 months", "period", "patient", "recurrent episodes of high-grade fever", "night sweats", "feelings", "fatigue", "Two months", "herpes zoster", "treated with acyclovir", "appears pale", "Temperature", "pulse", "90 min", "blood pressure", "80 mm Hg", "Physical examination shows generalized painless lymphadenopathy", "liver", "spleen", "palpated 23 cm", "right", "left costal margin", "Laboratory studies show", "Hematocrit", "Leukocyte", "mm3 Segmented", "Eosinophils 1", "Lymphocytes 50", "Monocytes", "Platelet", "Blood shows mature lymphocytes", "rupture easily", "appear", "artifacts", "blood smear", "Flow cytometry shows lymphocytes", "CD5", "CD19", "CD20", "following", "most appropriate treatment"]}
{"question": "A 61-year-old man is brought to the emergency room with chest pain. He developed severe, crushing, substernal chest pain 10 hours ago while he was hiking in the Adirondack mountains. He was with 2 friends at the time who gave him aspirin before carrying him 5 miles to a town to get phone service, where they then called emergency medical services. His past medical history is notable for hypertension, diabetes mellitus, and hyperlipidemia. He takes enalapril, metformin, and atorvastatin. He has a 20-pack-year smoking history and is an avid hiker. His temperature is 100°F (37.8°C), blood pressure is 102/60 mmHg, pulse is 130/min, and respirations are 28/min. He is diaphoretic and intermittently conscious. Bilateral rales are heard on pulmonary auscultation. An electrocardiogram demonstrates ST elevations in leads I and aVL. Despite appropriate management, the patient expires. An autopsy is performed demonstrating ischemia in the left atrium and posterior left ventricle. Which of the following vessels was most likely affected in this patient?", "answer": "Left circumflex artery", "options": {"A": "Left anterior descending artery", "B": "Left circumflex artery", "C": "Left coronary artery", "D": "Right marginal artery"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old man", "brought", "emergency room", "chest pain", "severe", "crushing", "substernal chest pain 10 hours", "hiking", "mountains", "2 friends", "time", "gave", "aspirin", "carrying", "5 miles", "town to", "phone service", "then called emergency medical services", "past medical history", "notable", "hypertension", "diabetes mellitus", "hyperlipidemia", "takes enalapril", "metformin", "atorvastatin", "20 smoking history", "avid", "temperature", "blood pressure", "60 mmHg", "pulse", "min", "respirations", "min", "diaphoretic", "conscious", "Bilateral rales", "heard", "pulmonary auscultation", "electrocardiogram demonstrates ST elevations", "leads I", "aVL", "appropriate management", "patient expires", "autopsy", "performed", "ischemia", "left atrium", "posterior left ventricle", "following vessels", "most likely affected", "patient"]}
{"question": "A 61-year-old man comes to the physician with several months of sharp, shooting pain in both legs. Twenty years ago, he had a painless ulcer on his penis that resolved without treatment. He has no history of serious illness. Examination shows small pupils that constrict with accommodation but do not react to light. Sensation to pinprick and light touch is decreased over the distal lower extremities. Patellar reflexes are absent bilaterally. His gait is unsteady and broad-based. This patient is at increased risk for which of the following complications?", "answer": "Thoracic aortic aneurysm", "options": {"A": "Atrioventricular block", "B": "Mitral valve regurgitation", "C": "Penile squamous cell carcinoma", "D": "Thoracic aortic aneurysm"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["61 year old man", "physician", "several months", "sharp", "shooting", "legs", "Twenty years", "painless ulcer", "penis", "resolved", "treatment", "history", "serious illness", "Examination shows small pupils", "accommodation", "not react", "light", "Sensation", "pinprick", "light touch", "decreased", "distal lower extremities", "Patellar", "absent", "gait", "unsteady", "broad based", "patient", "increased risk", "following complications"]}
{"question": "A 55-year-old woman presents with severe pruritus and fatigue. She denies any similar symptoms in the past. No significant past medical history. Upon physical examination, scleral icterus is present, and significant hepatosplenomegaly is noted. Mild peripheral edema is also present. Laboratory findings are significant for elevated serum levels of bilirubin, aminotransferases, alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGTP), immunoglobulins, as well as cholesterol (especially HDL fraction). Antiviral antibodies are not present. The erythrocyte sedimentation rate is also elevated. Anti-mitochondrial antibodies are found. A liver biopsy is performed, and the histopathologic examination shows bile duct injury, cholestasis, and granuloma formation. Which of the following is the most likely diagnosis in this patient?", "answer": "Primary biliary cirrhosis", "options": {"A": "Primary biliary cirrhosis", "B": "Hemolytic anemia", "C": "Hepatitis A", "D": "Gilbert syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["55 year old woman presents", "severe pruritus", "fatigue", "denies", "similar symptoms", "past", "significant past medical history", "physical examination", "scleral icterus", "present", "significant hepatosplenomegaly", "noted", "Mild peripheral edema", "present", "Laboratory findings", "significant", "elevated serum levels", "bilirubin", "aminotransferases", "alkaline phosphatase", "glutamyl transpeptidase", "immunoglobulins", "cholesterol", "HDL fraction", "Antiviral antibodies", "not present", "erythrocyte sedimentation rate", "elevated", "Anti mitochondrial antibodies", "found", "liver biopsy", "performed", "histopathologic examination shows bile duct injury", "cholestasis", "granuloma formation", "following", "most likely diagnosis", "patient"]}
{"question": "A 25-year-old man is brought to the emergency department after being found unconscious. He was at a college party exhibiting belligerent behavior when he suddenly passed out and fell to the ground. His past medical history is not known. His temperature is 100°F (37.8°C), blood pressure is 107/48 mmHg, pulse is 125/min, respirations are 19/min, and oxygen saturation is 99% on room air. The patient is covered with emesis and responds incoherently to questions. As the patient begins to wake up he continues vomiting. The patient is started on IV fluids, analgesics, and anti-emetics and begins to feel better. Thirty minutes later the patient presents with muscle rigidity and is no longer responding coherently to questions. His temperature is 103°F (39.4°C), blood pressure is 127/68 mmHg, pulse is 125/min, respirations are 18/min, and oxygen saturation is 98% on room air. The patient's basic laboratory studies are drawn and he is started on IV fluids, given lorazepam, and placed under a cooling blanket. Despite these initial measures, his symptoms persist. Which of the following is the best next step in management?", "answer": "Dantrolene", "options": {"A": "Acetaminophen", "B": "Dantrolene", "C": "Intubation", "D": "Supportive therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "found unconscious", "college party exhibiting belligerent behavior", "passed out", "fell", "past medical history", "not known", "temperature", "blood pressure", "48 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "patient", "covered", "emesis", "questions", "patient begins to wake up", "continues vomiting", "patient", "started", "IV fluids", "analgesics", "anti-emetics", "begins to feel better", "Thirty minutes later", "patient presents", "muscle rigidity", "longer", "questions", "temperature", "4C", "blood pressure", "68 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "patient's basic laboratory studies", "drawn", "started", "IV fluids", "given lorazepam", "placed", "cooling blanket", "initial measures", "symptoms", "following", "best next step", "management"]}
{"question": "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?", "answer": "Administration of oral ketorolac", "options": {"A": "Administration of oral ketorolac", "B": "Perform joint aspiration", "C": "Open reduction of the tuberosity", "D": "Application of a lower leg cast\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "of pain in", "right knee", "past week", "pain", "exacerbated", "jogging", "climbing", "stairs", "history", "trauma", "knee", "healthy", "active member", "school's gymnastics team", "vital signs", "normal limits", "Examination of", "right knee shows", "tender swelling", "proximal tibia", "range of motion", "full", "Knee extension", "resistance causes pain", "anterior proximal", "examinations shows", "abnormalities", "X-ray right shows anterior tibial soft tissue swelling", "fragmentation", "tuberosity", "following", "most appropriate next step"]}
{"question": "Three days after undergoing an open cholecystectomy, an obese 57-year-old woman has fever, chills, and a headache. She has right-sided chest pain that increases on inspiration and has had a productive cough for the last 12 hours. She had an episode of hypotension after the operation that resolved with intravenous fluid therapy. She underwent an abdominal hysterectomy 16 years ago for multiple fibroids of the uterus. She has smoked one pack of cigarettes daily for 17 years. She appears uncomfortable. Her temperature is 39°C (102.2°F), pulse is 98/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Inspiratory crackles are heard at the right lung base. The abdomen is soft and nontender. There is a healing surgical incision below the right ribcage. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Pneumonia", "options": {"A": "Pulmonary embolism", "B": "Subphrenic abscess", "C": "Pneumonia", "D": "Pneumothorax"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["Three days", "open cholecystectomy", "obese 57 year old woman", "fever", "chills", "headache", "right-sided chest pain", "increases", "inspiration", "productive cough", "12 hours", "episode of hypotension", "operation", "resolved", "intravenous", "abdominal hysterectomy", "years", "multiple", "uterus", "smoked one pack", "cigarettes daily", "years", "appears", "temperature", "pulse", "98 min", "respirations", "min", "blood pressure", "mm Hg", "Inspiratory crackles", "heard", "right lung base", "abdomen", "soft", "nontender", "healing", "right ribcage", "examination shows", "abnormalities", "following", "most likely diagnosis"]}
{"question": "A 55-year-old man presents with a red rash over his face for the last 3 months. The patient says he moved to Nevada 6 months ago because of a new job where he works outdoors; however, he worked indoors in an office before. His vital signs include: blood pressure 100/60 mm Hg, pulse 64/min, respiratory rate 18/min. The patient’s rash is shown in the exhibit. Which of the following is the best initial step in the treatment of this patient?", "answer": "Topical metronidazole", "options": {"A": "Oral tetracycline", "B": "Oral clonidine", "C": "Topical metronidazole", "D": "Topical benzoyl peroxide"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["55 year old man presents", "red rash", "face", "months", "patient", "moved to Nevada", "months", "new job", "works outdoors", "worked", "office", "vital signs include", "blood pressure 100 60 mm Hg", "pulse 64 min", "respiratory rate", "min", "patients rash", "shown", "exhibit", "following", "best initial step", "treatment", "patient"]}
{"question": "A previously healthy 46-year-old woman comes to the physician because of progressive shortness of breath, fatigue, and chest pain during exercise for the last 6 months. She does not smoke. Her maternal uncle had similar symptoms. Cardiac examination shows wide splitting of S2. The second component of S2 is loud and best heard at the 2nd left intercostal space. The lungs are clear to auscultation. Which of the following is the most likely cause of this patient's cardiac findings?", "answer": "Increased right ventricular afterload", "options": {"A": "Increased right ventricular preload", "B": "Increased left ventricular preload", "C": "Increased right ventricular afterload", "D": "Increased left-to-right shunting"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old woman", "physician", "of progressive shortness", "breath", "fatigue", "chest pain", "exercise", "last", "months", "not smoke", "maternal uncle", "similar symptoms", "Cardiac examination shows wide splitting", "S2", "second component", "S2", "loud", "best heard", "2nd left intercostal space", "lungs", "clear", "auscultation", "following", "most likely cause", "patient's findings"]}
{"question": "An 11-year-old boy presents to your office with pitting edema and proteinuria exceeding 3.5g in 24 hours. You suspect that this patient has experienced a loss of polyanions in his glomerular basement membranes. Which of the following findings would confirm your diagnosis?", "answer": "Selective albuminuria", "options": {"A": "WBC casts in the urine", "B": "Selective albuminuria", "C": "Negatively birefringent crystals in the urine", "D": "Bence-Jones proteinuria"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy presents", "office", "pitting edema", "proteinuria", "3", "hours", "suspect", "patient", "experienced", "loss", "polyanions", "glomerular basement membranes", "following findings", "confirm", "diagnosis"]}
{"question": "A 48-year-old woman comes to the physician because of intermittent pain in her neck, right shoulder, and arm, as well as a tingling sensation in her right hand. She first noticed her symptoms after she got off a rollercoaster ride 2 months ago. Physical examination shows weakness when extending the right wrist against resistance. An MRI of the head and neck is shown. This patient's condition is most likely the result of nerve root compression by a structure derived from which of the following embryologic layers?", "answer": "Notochord", "options": {"A": "Neural crest", "B": "Notochord", "C": "Neural tube", "D": "Surface ectoderm"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old woman", "physician", "of intermittent pain in", "neck", "right shoulder", "arm", "tingling sensation", "right hand", "first", "symptoms", "got", "months", "Physical examination shows weakness", "extending", "right wrist", "resistance", "MRI of", "head and neck", "shown", "patient's condition", "most likely", "result of nerve root compression", "structure derived", "following embryologic layers"]}
{"question": "A 32-year-old female is brought to the emergency room by her friend for acute onset abdominal pain. She states that she was in a kickboxing class when she suddenly developed left-sided abdominal pain. Her past medical history is significant for chlamydia. She is currently sexually active and does not use contraception. Her menstrual periods occur regularly every 30 days. Her last menstrual period ended 2 days ago. The patient’s temperature is 99°F (37.2°C), blood pressure is 110/68 mmHg, pulse is 88/min, and respirations are 14/min with an oxygen saturation of 98% on room air. On physical exam, there is left-sided, lower abdominal tenderness and guarding. Pelvic examination is notable for clear mucous in the vaginal introitus and tenderness of the left adnexa. A pelvic ultrasound with Doppler reveals a large amount of fluid in the rectouterine pouch. Which of the following is the most likely diagnosis?", "answer": "Ruptured ovarian cyst", "options": {"A": "Ectopic pregnancy", "B": "Ovarian torsion", "C": "Pelvic inflammatory disease", "D": "Ruptured ovarian cyst"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old female", "brought", "emergency room", "friend", "acute onset abdominal pain", "states", "class", "left-sided abdominal pain", "past medical history", "significant", "chlamydia", "currently sexually active", "not use contraception", "menstrual periods occur", "30 days", "last menstrual period ended 2 days", "patients temperature", "blood pressure", "68 mmHg", "pulse", "88 min", "respirations", "14 min", "oxygen saturation", "98", "room air", "physical exam", "left-sided", "lower abdominal tenderness", "guarding", "Pelvic examination", "notable", "clear mucous", "vaginal introitus", "tenderness", "left adnexa", "pelvic ultrasound", "Doppler reveals", "large amount", "fluid", "rectouterine pouch", "following", "most likely diagnosis"]}
{"question": "A 63-year-old man from the countryside presents with leg swelling and right upper abdominal tenderness. He reports a history of myocardial infarction 4 years ago, but he has no supporting documentation. At the moment, his only medication is aspirin. He also stated that he used to have ‘high blood sugars’ when checked in the hospital 4 years ago, but he did not follow up regarding this issue. He works as a farmer and noticed that it became much harder for him to work in the last few days because of fatigue and syncope. He has a 24-pack-year history of smoking and consumes alcohol occasionally. The vital signs include: blood pressure 150/90 mm Hg, heart rate 83/min, respiratory rate 16/min, and temperature 36.5℃ (97.7℉). On physical examination, the patient is pale and acrocyanotic. There is a visible jugular vein distention and bilateral lower leg pitting edema. The pulmonary auscultation is significant for occasional bilateral wheezes. Cardiac auscultation is significant for a decreased S1, S3 gallop, and grade 3/6 systolic murmur best heard at the left sternal border in the 4th left intercostal space. Abdominal percussion and palpation are suggestive of ascites. The hepatic margin is 3 cm below the right costal margin. Hepatojugular reflux is positive. Which of the following is the most likely clinical finding observed in this patient on an echocardiogram?", "answer": "Increased peak tricuspid regurgitation", "options": {"A": "Left ventricular ejection fraction of 41%", "B": "Increased peak tricuspid regurgitation", "C": "Hypokinetic wall of the left ventricle", "D": "Abnormal left ventricular relaxation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old man", "countryside presents", "leg swelling", "right upper abdominal tenderness", "reports", "history of myocardial infarction", "years", "supporting documentation", "only medication", "aspirin", "stated", "used to", "high blood sugars", "checked", "hospital", "years", "not follow up", "issue", "works", "farmer", "harder", "to work", "days", "fatigue", "syncope", "pack-year history of smoking", "alcohol occasionally", "vital signs include", "blood pressure", "90 mm Hg", "heart rate 83 min", "respiratory rate", "min", "temperature 36", "97", "physical examination", "patient", "pale", "visible jugular vein distention", "bilateral lower leg pitting edema", "pulmonary auscultation", "significant", "occasional bilateral wheezes", "Cardiac auscultation", "significant", "decreased S1", "S3 gallop", "grade", "6 systolic murmur best heard", "left sternal border", "4th left intercostal space", "Abdominal percussion", "palpation", "suggestive of ascites", "hepatic margin", "3 cm", "right costal margin", "Hepatojugular reflux", "positive", "following", "most likely clinical finding observed", "patient", "echocardiogram"]}
{"question": "A 36-year-old woman comes to the physician because of difficulty discarding items in her home. She says that the accumulation of things in her kitchen and dining room makes regular use of these spaces incredibly difficult. Her behavior started when she was in high school. She feels anxious when she tries to discard her possessions and her husband tries to clean and organize the home. This behavior frustrates her because most of the items she saves have little emotional or monetary value. She reports that there has been no improvement despite attending cognitive behavioral therapy sessions for the past 6 months. She now feels that her behavior is “taking over” her life. She does not drink, smoke, or use illicit drugs. She takes no medications. Her temperature is 36°C (96.8°F), pulse is 90/min, respirations are 12/min, and blood pressure is 116/80 mm Hg. On mental status examination, she is calm, alert, and oriented to person, place, and time. Her mood is depressed; her speech is organized, logical, and coherent; and there are no psychotic symptoms. Which of the following is the most appropriate next step in management?", "answer": "Fluoxetine", "options": {"A": "Fluoxetine", "B": "Lamotrigine", "C": "Buspirone", "D": "Methylphenidate"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old woman", "physician", "of difficulty", "items", "home", "accumulation", "things", "kitchen", "dining room makes regular use of", "spaces", "difficult", "behavior started", "high school", "feels anxious", "to", "possessions", "husband", "to clean", "organize", "home", "behavior", "most", "items", "saves", "little emotional", "monetary value", "reports", "improvement", "attending cognitive behavioral therapy sessions", "past 6 months", "now feels", "behavior", "taking", "life", "not drink", "smoke", "use illicit", "takes", "medications", "temperature", "96", "pulse", "90 min", "respirations", "min", "blood pressure", "80 mm Hg", "mental", "calm", "alert", "oriented to person", "place", "time", "mood", "depressed", "speech", "organized", "logical", "coherent", "psychotic symptoms", "following", "most appropriate next step", "management"]}
{"question": "A 59-year-old woman presents to her primary care provider complaining of diffuse bodily aches. She reports a 3-month history of gradually worsening pain in her shoulders and hips that is worse in her right hip. She has a history of hypertension and recurrent renal stones for which she takes lisinopril and hydrochlorothiazide. She was admitted to the hospital earlier in the year after falling in her front yard and sustaining a distal radius fracture and vertebral compression fracture. Her temperature is 98.5°F (36.9°C), blood pressure is 145/85 mmHg, pulse is 100/min, and respirations are 20/min. On exam, she is well-appearing with mild tenderness to palpation in her shoulders and hips. She has mild pain with hip flexion and shoulder abduction. She has full range of motion in her bilateral upper and lower extremities. Serum findings are notable for the following:\n\nSerum:\nNa+: 141 mEq/L\nCl-: 100 mEq/L\nK+: 4.8 mEq/L\nHCO3-: 22 mEq/L\nUrea nitrogen: 17 mg/dL\nGlucose: 110 mg/dL\nCreatinine: 1.12 mg/dL\nCa2+: 11.2 mg/dL\nPhosphate: 2.3 mg/dL\nMg2+: 1.9 mg/dL\nAlkaline phosphatase: 120 U/L\n\nA radiograph of this patient’s right hip would most likely reveal which of the following?", "answer": "Well-defined cystic lesion with peritrabecular fibrosis", "options": {"A": "Expansile lytic lesion with thin sclerotic margins", "B": "Medullary bone destruction with elevated periosteum from cortical bone", "C": "Poorly marginated lesion extending into adjacent soft tissue", "D": "Well-defined cystic lesion with peritrabecular fibrosis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["59 year old woman presents", "primary care provider", "diffuse", "aches", "reports", "3 month history", "worsening pain in", "shoulders", "hips", "worse", "right hip", "history of hypertension", "recurrent renal stones", "takes lisinopril", "hydrochlorothiazide", "admitted", "hospital earlier", "year", "falling", "front yard", "sustaining", "distal radius fracture", "vertebral", "temperature", "98", "36", "blood pressure", "85 mmHg", "pulse", "100 min", "respirations", "20 min", "exam", "well appearing", "mild tenderness", "palpation", "shoulders", "hips", "mild", "hip flexion", "shoulder abduction", "full range of motion", "bilateral upper", "lower extremities", "Serum findings", "notable", "following", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4.8 mEq/L HCO3", "mEq/L Urea nitrogen", "mg/dL Glucose", "mg/dL Creatinine", "1", "mg/dL Ca2", "mg/dL Phosphate", "2.3 mg/dL Mg2", "1.9 mg/dL Alkaline phosphatase", "U/L", "radiograph of", "patients right hip", "most likely reveal", "following"]}
{"question": "A 20-year-old woman is brought in for a psychiatric consultation by her mother who is concerned because of her daughter’s recent bizarre behavior. The patient’s father died from lung cancer 1 week ago. Though this has been stressful for the whole family, the daughter has been hearing voices and having intrusive thoughts ever since. These voices have conversations about her and how she should have been the one to die and they encourage her to kill herself. She has not been able to concentrate at work or at school. She has no other history of medical or psychiatric illness. She denies recent use of any medication. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 110/65 mm Hg, and temperature is 36.9°C (98.4°F). On physical exam, she appears gaunt and anxious. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. CMP, CBC, and TSH are normal. A urine toxicology test is negative. What is the patient’s most likely diagnosis?", "answer": "Brief psychotic disorder", "options": {"A": "Brief psychotic disorder", "B": "Adjustment disorder", "C": "Schizophrenia", "D": "Bereavement"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["20 year old woman", "brought", "psychiatric consultation", "mother", "concerned", "daughters recent bizarre behavior", "patients father died", "lung cancer 1 week", "stressful", "whole family", "daughter", "hearing voices", "intrusive thoughts ever", "voices", "conversations", "one to die", "to kill", "not", "able to concentrate", "work", "school", "history of medical", "psychiatric illness", "denies recent use of", "medication", "Today", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "65 mm Hg", "temperature", "36", "98 4F", "physical exam", "appears", "anxious", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "CMP", "CBC", "normal", "urine toxicology test", "negative", "patients", "likely diagnosis"]}
{"question": "A 58-year-old woman presents to the emergency department with difficulty breathing and a sensation that her heart was racing for the past 3 days. She adds that she has lost weight over the last 7 weeks, despite a good appetite, and is anxious most of the time with difficulty sleeping at night. She has smoked 10 cigarettes per day for the past 15 years. Her blood pressure is 100/55 mmHg, temperature is 36.5°C (97.7°F), and pulse is irregular with a rate of 140–150/min. On physical examination she is thin, frail, and appears anxious. Her palms are sweaty and there are fine tremors on extension of both hands. She has a palpable smooth thyroid mass. Examination of the eyes reveals bilateral exophthalmos. An electrocardiogram is obtained and shown in the picture. Which of the following has a strong positive correlation with this patient’s heart rhythm?", "answer": "Age", "options": {"A": "Digoxin blood level", "B": "PR interval", "C": "Age", "D": "Amiodarone blood level"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["58 year old woman presents", "emergency department", "difficulty breathing", "sensation", "heart", "racing", "past 3 days", "adds", "lost weight", "weeks", "good appetite", "anxious", "time", "difficulty sleeping", "night", "smoked 10 cigarettes", "day", "past", "years", "blood pressure", "100 55 mmHg", "temperature", "36", "97", "pulse", "irregular", "rate", "min", "physical examination", "thin", "frail", "appears anxious", "palms", "sweaty", "fine tremors", "extension of", "hands", "palpable smooth thyroid", "Examination of", "eyes reveals bilateral exophthalmos", "electrocardiogram", "obtained", "shown", "picture", "following", "strong positive correlation", "patients"]}
{"question": "A 27-year-old male suddenly develops severe abdominal cramping and bloody diarrhea. The patient reports consuming undercooked ground beef four days prior to the onset of the symptoms. Which of the following best describes the toxin-mediated mechanism of this disease process?", "answer": "Inhibition of the 60S ribosomal subunit, resulting in decreased protein synthesis in gastrointestinal mucosal cells", "options": {"A": "Depolymerization of actin filaments in gastrointestinal mucosal cells, leading to mucosal cell death", "B": "Increased pH of gastrointestinal lumen resulting in reduced mucosal absorption", "C": "Increased intracellular cAMP in gastrointestinal mucosal cells, resulting in decreased absorption and increased secretion in the digestive tract", "D": "Inhibition of the 60S ribosomal subunit, resulting in decreased protein synthesis in gastrointestinal mucosal cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old male", "severe abdominal cramping", "bloody diarrhea", "patient reports", "ground beef four days prior to", "onset", "symptoms", "following best", "toxin mediated mechanism", "disease process"]}
{"question": "A 46-year-old woman presents to her primary care physician with one week of intermittent nausea and vomiting. She does not have any sick contacts, and her medical history is significant only for diabetes well-controlled on metformin. She also complains of some weakness and back/leg pain. She says that she recently returned from traveling abroad and had been administered an antibiotic during her travels for an unknown infection. On presentation, her temperature is 98.6°F (37°C), blood pressure is 119/78 mmHg, pulse is 62/min, and respirations are 25/min. An EKG is obtained showing flattening of the T wave. After further testing, the physician prescribes a thiazide for this patient. Which of the following diseases is also associated with this patient's most likely diagnosis?", "answer": "Wilson disease", "options": {"A": "Rheumatoid arthritis", "B": "Sjogren syndrome", "C": "Systemic lupus erythematosus", "D": "Wilson disease"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "primary care physician", "one week", "intermittent nausea", "vomiting", "not", "sick contacts", "medical history", "significant only", "diabetes well-controlled", "metformin", "weakness", "back leg", "recently returned", "traveling abroad", "administered", "antibiotic", "travels", "unknown infection", "presentation", "temperature", "98", "blood pressure", "mmHg", "pulse", "62 min", "respirations", "min", "EKG", "obtained showing flattening", "T wave", "further testing", "physician", "thiazide", "patient", "following diseases", "associated with", "patient's", "likely diagnosis"]}
{"question": "A 33-year-old man presents to the emergency department after a motor vehicle collision. He was the front seat unrestrained driver in a head-on collision. The patient has a Glasgow Coma Scale of 5 and is subsequently intubated. Physical exam is notable for subcutaneous emphysema in the clavicular area. Needle decompression and chest tube placement are performed, and the patient is stabilized after receiving 2 units of blood and 2 liters of fluid. Chest radiography demonstrates proper tube location and resolution of the pneumothorax. The patient is transferred to the trauma intensive care unit. On the unit, a repeat chest radiograph is notable for a recurrent pneumothorax with the chest tube in place. Which of the following is the most likely diagnosis?", "answer": "Tracheobronchial rupture", "options": {"A": "Inappropriate chest tube placement", "B": "Spontaneous pneumothorax", "C": "Tension pneumothorax", "D": "Tracheobronchial rupture"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "motor vehicle collision", "front", "driver", "head", "collision", "patient", "Glasgow Coma Scale", "intubated", "Physical exam", "notable", "subcutaneous emphysema", "clavicular area", "Needle decompression", "chest tube placement", "performed", "patient", "stabilized", "receiving", "units of blood", "2 liters of fluid", "Chest radiography demonstrates", "tube location", "resolution", "pneumothorax", "patient", "transferred", "trauma intensive care unit", "unit", "repeat chest radiograph", "notable", "recurrent pneumothorax", "chest tube", "place", "following", "most likely diagnosis"]}
{"question": "A 55-year-old man is brought to the emergency department 12 hours after the sudden onset of shortness of breath and substernal chest pain at rest; the pain is increased by inspiration. He has also had a nonproductive cough, fever, and malaise for the past 5 days. He does not smoke or use illicit drugs. His temperature is 38°C (100.4°F), pulse is 125/min, respirations are 32/min, and blood pressure is 85/45 mm Hg. Physical examination shows distended neck veins. Auscultation of the chest discloses bilateral basilar rales and muffled heart sounds. An ECG shows sinus tachycardia, diffuse ST segment elevation, low voltage QRS complexes, and fluctuating R wave amplitude. Which of the following is the most likely diagnosis?", "answer": "Cardiac tamponade", "options": {"A": "Kawasaki disease", "B": "Rheumatic fever", "C": "Infective endocarditis", "D": "Cardiac tamponade"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["55 year old man", "brought", "emergency department 12 hours", "sudden onset of shortness", "breath", "chest pain at rest", "pain", "increased", "inspiration", "nonproductive cough", "fever", "malaise", "past 5 days", "not smoke", "use illicit", "temperature", "100 4F", "pulse", "min", "respirations", "min", "blood pressure", "85", "mm Hg", "Physical examination shows distended neck veins", "Auscultation of", "chest", "bilateral basilar rales", "heart sounds", "ECG shows sinus tachycardia", "diffuse ST segment elevation", "low voltage QRS complexes", "fluctuating R", "following", "most likely diagnosis"]}
{"question": "A 34-year-old man comes to the physician because of frequent headaches and blurry vision during the past 4 months. He has also had difficulties achieving an erection over the past few weeks. Physical examination shows a temporal visual field deficit bilaterally. An MRI of the brain shows an intrasellar mass. The mass is most likely derived from which of the following types of cells?", "answer": "Lactotrophs", "options": {"A": "Thyrotrophs", "B": "Lactotrophs", "C": "Somatotrophs", "D": "Gonadotrophs"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "frequent headaches", "blurry vision", "past", "months", "difficulties", "erection", "past", "weeks", "Physical examination shows", "temporal visual field deficit", "MRI of", "brain shows", "mass", "mass", "most likely derived", "of", "following types", "cells"]}
{"question": "A 33-year-old G2P1 woman presents to the office because of poor diabetic control. She is currently at 18 weeks gestation and admits to having poor control of her type 1 diabetes before becoming pregnant. Her family history is non-contributory. The physical examination shows a pregnant woman with a fundal height of 20 cm (7.9 in). An abdominal ultrasound is ordered. Which of the following is the most likely congenital abnormality shown on the ultrasound?", "answer": "Ventricular septal defect", "options": {"A": "Amelia", "B": "Sacral agenesis", "C": "Spina bifida", "D": "Ventricular septal defect"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "office", "poor diabetic control", "currently", "weeks gestation", "admits", "poor control", "type 1 diabetes", "pregnant", "family history", "non contributory", "physical examination shows", "pregnant woman", "fundal height", "20", "abdominal ultrasound", "ordered", "following", "most likely congenital abnormality shown", "ultrasound"]}
{"question": "A 45-year-old G3P3 presents complaining of the feeling of a foreign body in her vagina that worsens on standing. She does not have urinary or fecal incontinence or any other genitourinary symptoms. She has no known gynecologic diseases. There were no complications with her pregnancies, all of which were full-term vaginal deliveries. She is sexually active with her husband and no longer uses oral contraceptives. She has an 11 pack-year history of smoking. Her weight is 79 kg (174 lb) and her height is 155 cm (5 ft). Her vital signs are within normal limits. The physical examination is unremarkable. The gynecologic examination reveals descent of the cervix halfway towards the introitus. On Valsalva and standing, the cervix descents to the plane of the hymen. The uterus is not enlarged and the ovaries are non-palpable. Which of the following treatments is most reasonable to offer this patient?", "answer": "Support pessary", "options": {"A": "Support pessary", "B": "Space-filling pessary", "C": "Posterior colporrhaphy", "D": "Sacral colpopexy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old", "presents", "feeling", "foreign body", "vagina", "worsens", "standing", "not", "urinary", "fecal incontinence", "genitourinary symptoms", "known gynecologic diseases", "complications", "pregnancies", "full-term vaginal deliveries", "sexually active", "husband", "longer uses oral contraceptives", "11 pack year history of smoking", "weight", "kg", "height", "5 ft", "vital signs", "normal limits", "physical examination", "unremarkable", "gynecologic examination reveals descent", "cervix", "introitus", "Valsalva", "standing", "cervix descents", "plane", "hymen", "uterus", "not enlarged", "ovaries", "non-palpable", "following treatments", "most", "to", "patient"]}
{"question": "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?", "answer": "Infundibulopelvic ligament", "options": {"A": "Broad ligament", "B": "Ovarian ligament", "C": "Cardinal ligament", "D": "Infundibulopelvic ligament"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["36 year old woman", "gravida 2", "para 2", "emergency department", "sudden-onset", "severe right flank pain", "aerobics class", "pain started", "denies", "trauma", "region", "history of recurrent ovarian cysts", "Menses occur", "day intervals", "temperature", "99", "Abdominal examination shows tenderness", "right lower quadrant", "guarding", "Pelvic ultrasound shows", "large simple cyst", "right ovary", "artery flow", "detectable", "Doppler", "no flow detected", "right ovarian vein", "following ligaments", "most likely to", "involved"]}
{"question": "A 69-year-old woman comes to the physician for a routine health maintenance examination. She feels well. Physical examination shows nontender cervical and axillary lymphadenopathy. The spleen is palpated 5 cm below the costal margin. Her leukocyte count is 12,000/mm3 and platelet count is 217,000/mm3. Further evaluation is most likely to show which of the following findings?", "answer": "Smudge cells", "options": {"A": "Ringed sideroblasts", "B": "Teardrop cells", "C": "Smudge cells", "D": "Hypergammaglobulinemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["69 year old woman", "physician", "routine health maintenance examination", "feels well", "Physical examination shows nontender cervical", "axillary lymphadenopathy", "spleen", "palpated 5", "costal margin", "leukocyte count", "mm3", "platelet count", "mm3", "Further evaluation", "most likely to show", "following findings"]}
{"question": "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?", "answer": "Chlamydia trachomatis", "options": {"A": "Candida albicans", "B": "Neisseria gonorrhoeae", "C": "Chlamydia trachomatis", "D": "Haemophilus influenzae"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old married woman presents", "emergency department", "severe abdominal", "night", "scant vaginal", "visited", "physician", "year", "pelvic infection", "never treated", "insurance issues", "period", "delayed", "month", "afebrile", "pulse", "min", "blood pressure", "100 70 mm Hg", "examination", "abdomen", "distended", "tender", "pregnancy test", "positive", "complication", "infection", "following organisms", "likely led", "patients condition"]}
{"question": "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?", "answer": "Inosine monophosphate dehydrogenase", "options": {"A": "Inosine monophosphate dehydrogenase", "B": "DNA-dependent RNA polymerase", "C": "DNA gyrase", "D": "Dihydroorotate dehydrogenase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "clinic", "month history", "progressive fatigue", "history of intravenous heroin use", "Physical examination shows scleral icterus", "serum study", "positive", "hepatitis C RNA", "Therapy", "interferon", "initiated", "combination", "second drug", "expected beneficial effect", "additional drug", "most likely due to inhibition", "following enzymes"]}
{"question": "A 42-year-old male presents to his primary care physician complaining of fatigue. He has not been to the doctor since he was 22 years of age. He reports that over the past three months, he has felt tired and weak despite no changes in diet or exercise. He is otherwise healthy and takes no medications. Family history is notable for colorectal cancer in his father and paternal uncle, ovarian cancer in his paternal grandmother, and pancreatic cancer in his paternal uncle. Physical examination is notable for conjunctival pallor. A complete blood count reveals a hemoglobin of 9.1 g/dL and hematocrit of 31%. A stool sample is hemoccult positive and a colonoscopy reveals a fungating hemorrhagic mass in the ascending colon. Which of the following processes is most likely impaired in this patient?", "answer": "Mismatch repair", "options": {"A": "Base excision repair", "B": "Nucleotide excision repair", "C": "Mismatch repair", "D": "Non-homologous end joining"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male presents", "primary care physician", "fatigue", "not", "doctor", "years", "age", "reports", "past three months", "felt tired", "weak", "changes", "diet", "exercise", "healthy", "takes", "medications", "Family history", "notable", "colorectal cancer", "father", "paternal uncle", "ovarian cancer", "paternal grandmother", "pancreatic cancer", "paternal uncle", "Physical examination", "notable", "conjunctival pallor", "complete blood count reveals a hemoglobin", "1 g/dL", "hematocrit", "31", "stool sample", "hemoccult positive", "colonoscopy reveals", "fungating hemorrhagic mass", "ascending colon", "following processes", "most likely impaired", "patient"]}
{"question": "A 38-year-old woman presents to an urgent care clinic with the complaint of epigastric discomfort and cramping pain for the past 2 hours. She states that she has experienced similar pain in the past. These episodes occur mostly after meals and often subside several hours after she finishes eating. Due to this reason she mostly avoids eating. She says she has lost a few pounds in the last couple of months. She is a smoker and drinks alcohol occasionally. Past medical history is insignificant except for chronic knee pain, for which she takes over the counter painkillers. Her temperature is 37°C (98.6°F), respiratory rate is 16/min, pulse is 77/min, and blood pressure is 120/89 mm Hg. A physical abdominal exam is unremarkable, including examination of the abdomen. Which of the following is the most likely diagnosis?", "answer": "Gastric peptic ulcer", "options": {"A": "Choledocholithiasis", "B": "Pancreatitis", "C": "Gastric peptic ulcer", "D": "Gallbladder cancer"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "urgent care clinic", "complaint", "epigastric discomfort", "cramping pain", "past", "hours", "states", "similar pain", "past", "episodes occur mostly", "meals", "often", "several hours", "finishes eating", "reason", "mostly", "eating", "lost", "few pounds", "couple", "months", "smoker", "drinks alcohol occasionally", "Past medical history", "chronic knee pain", "takes over the counter painkillers", "temperature", "98", "respiratory rate", "min", "pulse", "min", "blood pressure", "mm Hg", "physical abdominal exam", "unremarkable", "including examination of", "abdomen", "following", "most likely diagnosis"]}
{"question": "A 19-year-old female college soccer player presents to a sports medicine clinic with right knee pain. One day prior she twisted her right knee and felt a “pop” while chasing after a ball. She has since felt severe throbbing knee pain and noticed a rapid increase in swelling around her knee. She is able to bear weight but feels “unstable” on her right leg. On exam, anterior drawer and Lachman’s tests are positive. The physician informs her that she has likely injured an important structure in her knee. What is the function of the structure that she has most likely injured?", "answer": "Prevent excess anterior translation of the tibia relative to the femur", "options": {"A": "Prevent excess posterior translation of the tibia relative to the femur", "B": "Prevent excess anterior translation of the tibia relative to the femur", "C": "Resist excess valgus force on the knee", "D": "Provide a cushion between the lateral tibial and femoral condyles"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female college soccer", "presents", "sports medicine clinic", "right", "One day prior", "twisted", "right knee", "felt", "ball", "since felt severe throbbing knee", "rapid increase", "swelling", "knee", "able to bear weight", "feels unstable on", "right leg", "exam", "anterior drawer", "Lachmans tests", "positive", "physician informs", "likely injured", "important structure", "knee", "function", "structure", "most likely injured"]}
{"question": "Six hours after birth, a newborn boy is evaluated for tachypnea. He was delivered at 41 weeks' gestation via Caesarian section and the amniotic fluid was meconium-stained. His respiratory rate is 75/min. Physical examination shows increased work of breathing. X-rays of the abdomen and chest show no abnormalities. Echocardiography shows elevated pulmonary artery pressure. He is started on an inhaled medication that increases smooth muscle cGMP, and there is immediate improvement in his tachypnea and oxygenation status. Three hours later, the newborn is tachypneic and there is blue-grey discoloration of the lips, fingers, and toes. Which of the following is the most likely cause of this infant's cyanosis?", "answer": "Oxidization of Fe2+ to Fe3+", "options": {"A": "Increase in concentration of serum myoglobin", "B": "Closure of the ductus arteriosus", "C": "Oxidization of Fe2+ to Fe3+", "D": "Allosteric alteration of heme groups"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Six hours after birth", "newborn boy", "evaluated", "tachypnea", "delivered", "weeks", "gestation", "Caesarian section", "amniotic fluid", "meconium stained", "respiratory rate", "75 min", "Physical examination shows increased work of breathing", "X-rays of", "abdomen", "chest show", "abnormalities", "Echocardiography shows elevated pulmonary artery pressure", "started", "inhaled medication", "increases smooth muscle cGMP", "immediate improvement", "tachypnea", "oxygenation status", "Three hours later", "newborn", "tachypneic", "blue grey discoloration", "lips", "fingers", "toes", "following", "most likely cause", "infant's cyanosis"]}
{"question": "A study is conducted to determine the most effective ways to prevent transmission of various infective agents. One of the agents studied is a picornavirus that preferentially infects hepatocytes. The investigator determines that inactivating this virus can prevent its spread. Which of the following disinfectants is most likely to inactivate this virus?", "answer": "Sodium hypochlorite", "options": {"A": "Chlorhexidine", "B": "Sodium hypochlorite", "C": "Sulfuric acid", "D": "Ethyl alcohol"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["study", "conducted to", "most effective", "to prevent transmission", "various infective agents", "One", "studied", "picornavirus", "infects hepatocytes", "investigator", "virus", "prevent", "spread", "following disinfectants", "most likely to", "virus"]}
{"question": "A 34-year-old woman comes to the physician requesting prenatal care. For the past 2 months, she has had increasing breast tenderness, nausea, 3-kg (6.6-lb) weight gain, and urinary frequency. She is not sure about the date of her last menstrual period. She has been trying to conceive with her husband since she stopped taking oral contraceptives 6 months ago; she was happy to tell him last week that she is pregnant. Her temperature is 37.2°C (99°F), pulse is 100/min, and blood pressure is 110/60 mm Hg. Physical examination shows mild, nontender abdominal enlargement. The cervical os is closed. Urine β-hCG is negative. Transvaginal ultrasonography shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Pseudocyesis", "options": {"A": "Delusion of pregnancy", "B": "Pseudocyesis", "C": "Pregnancy", "D": "Incomplete abortion"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician requesting prenatal care", "past", "months", "increasing breast tenderness", "nausea", "3 kg", "6.6", "weight gain", "urinary frequency", "not sure", "date of", "last menstrual period", "to", "husband", "stopped taking oral contraceptives", "months", "happy to", "last week", "pregnant", "temperature", "pulse", "100 min", "blood pressure", "60 mm Hg", "Physical examination shows mild", "nontender abdominal enlargement", "cervical os", "closed", "Urine", "hCG", "negative", "Transvaginal ultrasonography shows", "abnormalities", "following", "most likely diagnosis"]}
{"question": "A 60-year-old man comes to the physician for a routine physical examination. He lives in a group home and takes no medications. During the appointment, he frequently repeats the same information and needs to be reminded why he is at the doctor's office. He says that he is a famous poet and recently had a poem published in a national magazine. His vital signs are within normal limits. He has a constricted affect. Neurological examination shows no focal deficits. On mental status examination, he has no long-term memory deficits and is able to count in serial sevens without error. An MRI of the brain shows atrophy of the anterior thalami and small mamillary bodies. Which of the following is the most likely predisposing factor for this patient's condition?", "answer": "Alcohol use disorder", "options": {"A": "Consumption of undercooked meat", "B": "Chronic hypertension", "C": "Alcohol use disorder", "D": "Spirochete infection"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "physician", "routine physical examination", "lives", "a group home", "takes", "medications", "appointment", "frequently repeats", "same information", "needs to", "reminded", "doctor's office", "famous poet", "recently", "poem published", "national magazine", "vital signs", "normal limits", "constricted affect", "Neurological examination shows", "focal deficits", "mental", "long-term memory deficits", "able to count", "serial", "error", "MRI of", "brain shows atrophy", "anterior thalami", "small mamillary bodies", "following", "most likely predisposing factor", "patient's condition"]}
{"question": "A medical student decides to join an immunology research center, which specifically works on capsular polysaccharide vaccine development against bacteria, such as Haemophilus influenzae type b (Hib), Neisseria meningitidis, and Streptococcus pneumoniae. As a member of a research team working on the Hib vaccine, he asks his senior colleague why capsular polysaccharides are conjugated to protein carriers like tetanus toxoid during vaccine development. Which of the following is the best response to this question?", "answer": "Conjugation with a protein carrier provides effective protection to infants", "options": {"A": "Conjugation with a protein carrier generates IgG2 dominant antibody responses", "B": "Conjugation with a protein carrier generates IgM dominant antibody responses", "C": "Conjugation with a protein carrier improves vaccine stability", "D": "Conjugation with a protein carrier provides effective protection to infants"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["medical student", "to", "immunology research center", "works", "capsular polysaccharide", "bacteria", "Haemophilus influenzae type b", "Neisseria meningitidis", "Streptococcus pneumoniae", "member", "research team working", "Hib vaccine", "senior", "capsular polysaccharides", "conjugated", "protein carriers", "tetanus toxoid", "vaccine development", "following", "best response", "question"]}
{"question": "An investigator is studying the pattern of glutamate release from presynaptic nerve terminals in human volunteers with Alzheimer disease. The concentration of glutamate in the CA1 region of the hippocampus is measured using magnetic resonance spectroscopy after Schaffer collateral fibers are electrically stimulated. Which of the following events most likely occurs immediately prior to the release of neurotransmitters?", "answer": "Influx of calcium", "options": {"A": "Activation of G protein-coupled receptors", "B": "Accumulation of cAMP", "C": "Opening of ligand-gated ion channels", "D": "Influx of calcium"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "pattern", "glutamate release", "presynaptic nerve terminals", "human volunteers", "Alzheimer disease", "concentration", "glutamate", "CA1 region", "hippocampus", "measured using magnetic resonance spectroscopy", "Schaffer collateral fibers", "electrically stimulated", "following events", "likely occurs immediately prior to", "release", "neurotransmitters"]}
{"question": "A 24-year-old woman presents to a physician with a history of exposure to a close friend who was diagnosed with meningococcal meningitis. She was told by her friend that she need to see a physician because she needs to be treated as well, even if she is not having symptoms yet. She currently denies any headaches, vision changes, nausea or vomiting, or neck stiffness. Her physical exam is within normal limits. Her vital signs are stable. She is prescribed rifampin for prophylaxis with specific instructions on when to follow up if symptoms develop. When asked about the possibility of pregnancy, she mentioned that she uses combination oral contraceptive pills (OCPs) for contraception. The physician suggested that her husband should use condoms for contraception as she requires antibiotic therapy. Which of the following mechanisms best explains the need for additional contraception?", "answer": "Rifampin alters normal gastrointestinal flora, which leads to a decrease in the enterohepatic circulation of estrogens.", "options": {"A": "Rifampin alters normal gastrointestinal flora, which leads to a decrease in the enterohepatic circulation of estrogens.", "B": "Rifampin inhibits CYP3A4, which metabolizes progestins.", "C": "Rifampin alters normal gastrointestinal flora, which leads to a decrease in the enterohepatic circulation of progestins.", "D": "Rifampin directly interferes with intestinal absorption of estrogens."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "physician", "history", "exposure", "close friend", "diagnosed", "meningococcal meningitis", "friend", "need to see", "physician", "needs to", "treated", "well", "not", "symptoms", "currently denies", "headaches", "vision changes", "nausea", "vomiting", "neck stiffness", "physical exam", "normal limits", "vital signs", "stable", "prescribed rifampin", "prophylaxis", "specific instructions", "to follow up", "symptoms", "possibility", "pregnancy", "uses combination oral contraceptive pills", "contraception", "physician suggested", "husband", "use condoms", "contraception", "antibiotic therapy", "following mechanisms best", "need", "additional contraception"]}
{"question": "A 38-year-old woman comes to the physician because of a 1-month history of a painless, nonpruritic skin lesion on her right thigh. She initially thought it was an insect bite, but it has slowly increased in size over the past weeks. Her temperature is 36.7°C (98°F), pulse is 75/min, and blood pressure is 128/76 mm Hg. Physical examination shows a 0.8-cm hyperpigmented papule. When the skin lesion is squeezed, the surface retracts inwards. A photograph of the lesion is shown. Which of the following is the most likely diagnosis?", "answer": "Dermatofibroma", "options": {"A": "Dermatofibroma", "B": "Cherry hemangioma", "C": "Actinic keratosis", "D": "Seborrheic keratosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "1-month history", "painless", "nonpruritic skin lesion", "right thigh", "initially thought", "insect bite", "slowly increased in size", "past weeks", "temperature", "36", "pulse", "75 min", "blood pressure", "76 mm Hg", "Physical examination shows", "0.8", "hyperpigmented papule", "skin lesion", "squeezed", "surface retracts inwards", "photograph", "lesion", "shown", "following", "most likely diagnosis"]}
{"question": "A previously healthy 3-year-old boy is brought to the physician by his parents because of fever and a rash for 6 days. His temperature is 38.9°C (102°F). Examination shows right-sided anterior cervical lymphadenopathy, bilateral conjunctival injection, erythema of the tongue and lips, and a maculopapular rash involving the hands, feet, perineum, and trunk. Which of the following is the most common complication of this patient's condition?", "answer": "Coronary artery aneurysm", "options": {"A": "Coronary artery aneurysm", "B": "Rapidly progressive glomerulonephritis", "C": "Hearing loss", "D": "Retinopathy"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old boy", "brought", "physician", "parents", "fever", "rash", "6 days", "temperature", "Examination shows right-sided", "bilateral conjunctival injection", "erythema", "tongue", "lips", "maculopapular rash involving", "hands", "feet", "perineum", "trunk", "following", "most common complication", "patient's condition"]}
{"question": "A 25-year-old man is brought to the emergency department by police. He was found at a local celebration acting very strangely and was reported by other patrons of the event. The patient is very anxious and initially is hesitant to answer questions. He denies any substance use and states that he was just trying to have a good time. The patient's responses are slightly delayed and he seems to have difficulty processing his thoughts. The patient tells you he feels very anxious and asks for some medication to calm him down. The patient has a past medical history of psoriasis which is treated with topical steroids. His temperature is 99.5°F (37.5°C), blood pressure is 120/75 mmHg, pulse is 110/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note an anxious young man. HEENT exam reveals a dry mouth and conjunctival injection. Neurological exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in his upper and lower extremities. Cardiac exam reveals tachycardia, and pulmonary exam is within normal limits. Which of the following is the most likely intoxication in this patient?", "answer": "Marijuana", "options": {"A": "Alcohol", "B": "Marijuana", "C": "Cocaine", "D": "Phencyclidine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "police", "found", "local", "acting very", "reported by", "event", "patient", "very anxious", "initially", "hesitant to answer questions", "denies", "substance use", "states", "to", "good time", "patient's responses", "slightly delayed", "to", "difficulty processing", "thoughts", "patient", "feels very anxious", "medication to calm", "patient", "past medical", "treated with topical steroids", "temperature", "99", "blood pressure", "75 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "physical exam", "note", "anxious young man", "HEENT exam reveals", "dry mouth", "conjunctival injection", "Neurological exam reveals cranial nerves II XII", "intact", "normal strength", "sensation", "upper", "lower extremities", "Cardiac exam reveals tachycardia", "pulmonary exam", "normal limits", "following", "most likely intoxication", "patient"]}
{"question": "A 75-year-old with hypertension and atrial fibrillation comes to the emergency department because of a 2-hour history of severe abdominal pain and nausea. He has smoked 1 pack of cigarettes daily for the past 45 years. The patient undergoes emergency laparotomy and is found to have dusky discoloration of the hepatic colonic flexure and an adjacent segment of the transverse colon. The most likely cause of his condition is occlusion of a branch of which of the following arteries?", "answer": "Superior mesenteric artery", "options": {"A": "Median sacral artery", "B": "Inferior mesenteric artery", "C": "Celiac artery", "D": "Superior mesenteric artery"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["75 year old", "hypertension", "atrial fibrillation", "emergency department", "2-hour history", "severe abdominal", "nausea", "smoked 1 pack", "cigarettes daily", "past", "years", "patient", "emergency laparotomy", "found to", "dusky discoloration", "hepatic colonic flexure", "adjacent segment of", "transverse colon", "most likely cause", "condition", "occlusion", "branch", "following arteries"]}
{"question": "A group of researchers from Italy conducted a case register study that included all patients from a city who had an International Classification of Diseases diagnosis and contacts with specialist psychiatric services over a 10-year period. Mortality was studied in relation to age, sex, diagnosis, care pattern, and registration interval. Standardized mortality ratios (SMRs) were calculated, with the overall SMR being 1.63 (lower when compared with studies that looked at hospitalized individuals). Men and those in younger age groups showed higher mortality rates (SMRs of 2.24 and 8.82, respectively), and mortality was also higher in the first year following registration (SMR = 2.32). Higher mortality was also found in patients with a diagnosis of alcohol and drug dependence (SMR = 3.87). The authors concluded that the overall mortality of psychiatric patients managed in a community-based setting was higher than expected; however, it was still lower than the mortality described in other psychiatric settings. The primary measure used in this study can be defined as which of the following?", "answer": "The observed number of deaths divided by the expected number of deaths", "options": {"A": "The total number of deaths divided by the mid-year population", "B": "The number of deaths in a specific age group divided by a mid-year population in that age group", "C": "The observed number of deaths divided by the expected number of deaths", "D": "The number of deaths from a certain disease in 1 year divided by the total number of deaths in 1 year"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A group", "researchers", "Italy conducted", "case", "study", "included", "patients", "city", "International Classification of Diseases diagnosis", "contacts with specialist psychiatric services", "a 10 year period", "Mortality", "studied", "relation to age", "sex", "diagnosis", "care pattern", "registration interval", "Standardized mortality ratios", "calculated", "overall SMR", "1 63", "lower", "compared", "studies", "looked", "hospitalized individuals", "Men", "younger age groups showed higher mortality rates", "SMRs", "mortality", "higher", "first year following registration", "SMR", "2", "Higher mortality", "found", "patients", "diagnosis", "alcohol", "drug dependence", "SMR", "3 87", "authors concluded", "overall mortality", "psychiatric patients managed", "community based setting", "higher", "expected", "lower", "mortality described", "psychiatric settings", "primary measure used", "study", "defined"]}
{"question": "A 10-year-old boy is brought to the emergency room by his grandparents. He is in a wheelchair with soft restraints because he has been violent and had been trying to hurt himself that day. The child’s parents died in a car accident 1 month ago. His grandparents also brought the medications he stopped taking after his parents’ death, including multivitamins, allopurinol, and diazepam. They say that their grandson has been using these medications for many years; however, they are unable to provide any medical history and claim that their grandson has been behaving strangely, exhibiting facial grimacing, irregular involuntary contractions, and writhing movements for the past few days. They also note that he has had no teeth since the time they first met him at the age of 2. An intramuscular medication is administered to calm the boy down prior to drawing blood from him for laboratory tests. Which of the following biochemical pathway abnormalities is the most likely cause of this patient’s condition?", "answer": "Hypoxanthine-guanine phosphoribosyl transferase of the purine metabolism pathway", "options": {"A": "Hypoxanthine-guanine phosphoribosyl transferase of the pyrimidine metabolism pathway", "B": "Aminolevulinic acid synthetase of the heme metabolism pathway", "C": "Hypoxanthine-guanine phosphoribosyl transferase of the purine metabolism pathway", "D": "Thymidylate synthetase of the pyrimidine metabolism pathway"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A 10 year old boy", "brought", "emergency room", "grandparents", "wheelchair", "soft restraints", "violent", "to", "day", "childs parents died", "car accident", "month", "grandparents", "brought", "medications", "stopped", "parents death", "including multivitamins", "allopurinol", "diazepam", "grandson", "using", "medications", "years", "unable to provide", "medical history", "grandson", "exhibiting facial grimacing", "irregular involuntary contractions", "writhing movements", "past", "days", "note", "teeth", "time", "first met", "age", "intramuscular medication", "administered to calm", "boy", "prior to drawing blood", "laboratory tests", "following biochemical pathway abnormalities", "most likely cause", "patients condition"]}
{"question": "A 34-year-old woman with poorly controlled Crohn disease comes to the physician because of a 2-week history of hair loss and a rash on her face. She has also noticed that food has recently tasted bland to her. She had to undergo segmental small bowel resection several times because of intestinal obstruction and fistula formation. Examination shows several bullous, erythematous perioral plaques. There are two well-circumscribed circular patches of hair loss on the scalp. A deficiency of which of the following is the most likely cause of this patient's condition?", "answer": "Zinc", "options": {"A": "Niacin", "B": "Cobalamin", "C": "Iron", "D": "Zinc"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "poorly controlled Crohn", "physician", "of", "2-week history", "hair loss", "rash on", "face", "food", "recently tasted", "to", "segmental small bowel resection", "times", "of intestinal obstruction", "fistula formation", "Examination shows several bullous", "erythematous perioral plaques", "two well circumscribed circular patches of hair loss", "scalp", "deficiency", "following", "most likely cause", "patient's condition"]}
{"question": "A 23-year-old woman, gravida 2, para 1, at 20 weeks of gestation comes to the physician for a routine prenatal exam. Her last pregnancy was unremarkable and she gave birth to a healthy rhesus (RhD) positive girl. Her past medical history is notable for a blood transfusion after a car accident with a complex femur fracture about 3 years ago. Her temperature is 37.2°C (99°F), pulse is 92/min, and blood pressure is 138/82 mm Hg. Examination shows that the uterus is at the umbilicus. Ultrasound examination reveals normal fetal heart rate, movement, and anatomy. Routine prenatal labs show the following:\nBlood type A Rh-\nLeukocyte count 11,000/mm3\nHemoglobin 12.5 g/dL\nPlatelet count 345,000/mm3\nSerum\nAnti-D antibody screen Negative\nRubella IgM Negative\nRubella IgG Negative\nVaricella IgM Negative\nVaricella IgG Positive\nSTD panel Negative\nUrine\nProtein Trace\nCulture No growth\nCervical cytology Normal\nWhich of the following is the best next step in management of this patient?\"", "answer": "Repeat antibody screening at 28 weeks. Administer anti-D immunoglobulin at 28 weeks and after delivery if the newborn is Rh(D) positive.", "options": {"A": "Repeat antibody screening at 28 weeks. Administer anti-D immunoglobulin at 28 weeks and after delivery if the newborn is Rh(D) positive.", "B": "Repeat antibody screening at 28 weeks and administer anti-D immunoglobulin at 28 weeks. No further management is needed.", "C": "No further screening is needed. Administer anti-D immunoglobulin shortly after delivery", "D": "No further management is needed\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["23 year old woman", "gravida 2", "para 1", "20 weeks of gestation", "physician", "routine prenatal exam", "last pregnancy", "unremarkable", "gave birth", "healthy rhesus", "RhD", "positive girl", "past medical history", "notable", "blood transfusion", "car accident", "complex femur fracture", "3 years", "temperature", "pulse", "min", "blood pressure", "mm Hg", "Examination shows", "uterus", "umbilicus", "Ultrasound examination reveals normal fetal heart rate", "movement", "anatomy", "Routine prenatal labs show", "following", "Blood type", "Rh", "Leukocyte", "mm3", "12", "Platelet", "antibody", "Rubella", "Positive", "panel", "Urine", "Trace Culture", "growth Cervical cytology Normal", "following", "best next step", "management", "patient"]}
{"question": "A 52-year-old man presents to the physician because of ongoing shortness of breath, which is more prominent when he lies down. Occasionally, he experiences palpitations, especially during strenuous activities. In addition to this, he has been experiencing difficulty in digestion and often experiences regurgitation and dysphagia. He reports that he emigrated from Mexico 20 years ago and visits his hometown twice a year. The vital signs include: blood pressure 120/75 mm Hg, respiratory rate 19/min, and pulse 100/min. The physical examination shows jugular vein distention along with pitting edema in the ankles. Bilateral basilar crackles and an S3 gallop are heard on auscultation of the chest. A chest X-ray is taken. An electrocardiogram (ECG) shows no significant findings. What is the most likely explanation for this patient’s physical and diagnostic findings?", "answer": "Parasitic infection", "options": {"A": "Alcohol abuse", "B": "Hypertensive changes", "C": "Parasitic infection", "D": "Bacterial infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "physician", "of ongoing shortness", "breath", "more prominent", "Occasionally", "experiences palpitations", "strenuous activities", "experiencing difficulty", "digestion", "often experiences regurgitation", "dysphagia", "reports", "Mexico 20 years", "visits", "twice", "year", "vital signs include", "blood pressure", "75 mm Hg", "respiratory rate", "min", "pulse 100 min", "physical examination shows jugular vein distention", "pitting edema", "ankles", "Bilateral basilar crackles", "S3 gallop", "heard", "auscultation", "chest", "chest X-ray", "taken", "electrocardiogram", "shows", "significant findings", "most likely explanation", "patients physical", "diagnostic findings"]}
{"question": "A 33-year-old woman presents to her primary care physician with bilateral joint pain. She says that the pain has been slowly worsening over the past 3 days. Otherwise, she complains of fatigue, a subjective fever, and a sunburn on her face which she attributes to gardening. The patient is an immigrant from Spain and works as an office assistant. She is not aware of any chronic medical conditions and takes a multivitamin daily. Her temperature is 98.7°F (37.1°C), blood pressure is 125/64 mmHg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam reveals bilateral redness over the maxillary prominences. Which of the following is most likely to be seen in this patient?", "answer": "Decreased complement levels", "options": {"A": "Decreased complement levels", "B": "Increased anti-centromere antibodies", "C": "Increased anti-cyclic citrullinated peptide antibodies", "D": "Increased anti-topoisomerase antibodies"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "bilateral joint pain", "pain", "slowly worsening", "past 3 days", "fatigue", "subjective fever", "sunburn", "face", "attributes", "gardening", "patient", "immigrant", "Spain", "works", "office assistant", "not aware", "chronic medical conditions", "takes", "multivitamin daily", "temperature", "98", "blood pressure", "64 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam reveals bilateral redness", "maxillary prominences", "following", "most likely to", "seen", "patient"]}
{"question": "A 40-year-old man comes to the emergency department with a 4-day history of left leg pain. Over the weekend, he scraped his left thigh when he fell on a muddy field while playing flag football with some friends. Since that time, he has had progressively worsening redness and pain in his left thigh. Past medical history is unremarkable. His temperature is 39.4°C (103.0°F), heart rate is 120/min, and blood pressure is 95/60 mm Hg. Physical exam is significant for a poorly-demarcated area of redness on his left thigh, extending to about a 10 cm radius from a small scrape. This area is extremely tender to palpation, and palpation elicits an unusual 'crunchy' sensation. CT scan shows free air in the soft tissue of the left leg. The organism that is most likely responsible for this patient's presentation is also a common cause of which of the following conditions?", "answer": "Food-borne illness", "options": {"A": "Bacterial pneumonia", "B": "Bacterial sinusitis", "C": "Food-borne illness", "D": "Urinary tract infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old man", "emergency department", "4-day history", "left leg pain", "weekend", "scraped", "left thigh", "fell", "muddy field", "playing flag football", "friends", "Since", "time", "worsening redness", "pain in", "left thigh", "Past medical history", "unremarkable", "temperature", "4C", "heart rate", "min", "blood pressure", "95 60 mm Hg", "Physical exam", "significant", "poorly", "area", "redness", "left thigh", "extending to", "10", "radius", "small scrape", "area", "extremely tender", "palpation", "palpation elicits", "unusual", "sensation", "CT scan shows free air", "soft tissue", "left leg", "organism", "most likely responsible", "patient's presentation", "common cause", "following conditions"]}
{"question": "A 75-year-old man presents to the emergency department with a racing heart and lightheadedness for 3 hours. He has had similar episodes in the past, but the symptoms never lasted this long. He denies chest pain, shortness of breath, headaches, and fevers. He had a myocardial infarction 4 years ago and currently takes captopril, metoprolol, and atorvastatin. His pulse is irregular and cardiac auscultation reveals an irregular heart rhythm. Laboratory reports show:\nSerum glucose 88 mg/dL\nSodium 142 mEq/L\nPotassium 3.9 mEq/L\nChloride 101 mEq/L\nSerum creatinine 0.8 mg/dL\nBlood urea nitrogen 10 mg/dL\nCholesterol, total 170 mg/dL\nHDL-cholesterol 40 mg/dL\nLDL-cholesterol 80 mg/dL\nTriglycerides 170 mg/dL\nHematocrit 38%\nHemoglobin 13 g/dL\nLeucocyte count 7,500/mm3\nPlatelet count 185,000 /mm3\nActivated partial thromboplastin time (aPTT) 30 seconds\nProthrombin time (PT) 12 seconds\nCardiac enzymes Negative\nAn ECG shows the absence of P-waves with an irregular RR complex. A few hours later, his symptoms subside and he is discharged with an additional anticoagulation drug. Which of the following mechanisms explains how this new medication will exert its effects?", "answer": "Inhibition of vitamin K-dependent clotting factors", "options": {"A": "Activation of the antithrombin enzyme", "B": "Inhibition of the cyclooxygenase enzyme", "C": "Inhibition of vitamin K-dependent clotting factors", "D": "Blockage of glycoprotein IIb/IIIa receptors"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["75 year old man presents", "emergency department", "racing heart", "lightheadedness", "hours", "similar episodes", "past", "symptoms never lasted", "long", "denies chest pain", "shortness of breath", "headaches", "fevers", "myocardial infarction", "years", "currently takes captopril", "metoprolol", "atorvastatin", "pulse", "irregular", "cardiac auscultation reveals", "irregular heart rhythm", "Laboratory reports show", "Serum glucose 88", "mEq/L Potassium", "Chloride", "creatinine 0.8", "urea nitrogen", "Cholesterol", "total", "HDL-cholesterol", "LDL-cholesterol 80", "Hemoglobin", "Leucocyte", "500 mm3 Platelet count", "Activated partial thromboplastin time", "30 seconds", "12", "Cardiac enzymes Negative", "ECG shows", "absence", "P-waves", "irregular RR complex", "few hours later", "symptoms", "discharged", "additional anticoagulation drug", "following mechanisms", "new medication", "exert", "effects"]}
{"question": "A 31-year-old man, who was hospitalized for substance-induced psychosis two days prior, has had episodic neck stiffness and pain for the past 8 hours. These episodes last for approximately 25 minutes and are accompanied by his neck rotating to the right. During the last episode, he was able to relieve the stiffness by lightly touching his jaw. He has received six doses of haloperidol for auditory hallucinations since his admission. He appears anxious. His temperature is 37.3°C (99.1°F), pulse is 108/min, and blood pressure is 128/86 mm Hg. Examination shows a flexed neck rotated to the right. The neck is rigid with limited range of motion. Which of the following is the most appropriate therapy for this patient's symptoms?", "answer": "Benztropine", "options": {"A": "Benztropine", "B": "Physical therapy", "C": "Dantrolene", "D": "Baclofen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["31 year old man", "hospitalized", "substance induced psychosis two days prior", "episodic neck stiffness", "pain", "past 8 hours", "episodes last", "approximately", "minutes", "neck rotating", "right", "last episode", "able to relieve", "stiffness", "lightly touching", "jaw", "received six doses", "haloperidol", "auditory hallucinations", "admission", "appears anxious", "temperature", "3C", "99", "pulse", "min", "blood pressure", "mm Hg", "Examination shows", "flexed neck rotated", "right", "neck", "rigid", "limited range of motion", "following", "most appropriate therapy", "patient's symptoms"]}
{"question": "A 31-year-old man presents to his primary care physician with fevers, chills, and night sweats. After a physical exam and a series of laboratory tests, the patient undergoes a lymph node biopsy (Image A). Three days later, while awaiting treatment, he presents to his physician complaining of generalized swelling and is found to have 4+ protein in his urine. Which of the following pathological findings is most likely to be found on renal biopsy in this patient?", "answer": "Minimal change disease", "options": {"A": "Rapidly progresive glomerulonephritis", "B": "Amyloidosis", "C": "Focal segmental glomerulosclerosis", "D": "Minimal change disease"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["31 year old man presents", "primary care physician", "fevers", "chills", "night sweats", "physical exam", "series", "laboratory tests", "patient", "lymph node biopsy", "Image", "Three days later", "treatment", "presents", "physician", "generalized swelling", "found to", "4", "protein in", "urine", "following pathological findings", "most likely to", "found", "renal biopsy", "patient"]}
{"question": "A microbiologist has isolated several colonies of Escherichia coli on an agar plate. The microbiologist exposes the agar plate to ciprofloxacin, which destroys all of the bacteria except for one surviving colony. Which of the following is the most likely mechanism of antibiotic resistance in the surviving colony?", "answer": "Mutation of DNA gyrase", "options": {"A": "Replacement of D-alanine", "B": "Mutation of DNA gyrase", "C": "Inactivation by bacterial transferase", "D": "Modification of surface binding proteins"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["microbiologist", "isolated", "colonies", "Escherichia coli", "agar plate", "microbiologist", "agar plate", "ciprofloxacin", "destroys", "bacteria", "one surviving colony", "following", "most likely mechanism", "antibiotic resistance", "surviving colony"]}
{"question": "A 48-year-old man is brought to the emergency department by his son with a fever over the past day. The patient’s son adds that his father has been having some behavioral problems, as well, and that he was complaining about bugs crawling over his skin this morning even though there were no insects. Past medical history is unremarkable. No current medications. The patient was an alcoholic for several years but abruptly quit drinking 5 days ago. The patient’s temperature is 40.0°C (104.0°F), pulse is 130/min, blood pressure is 146/88 mm Hg, and respiratory rate is 24/min. On physical examination, he is confused, restless, agitated, and lacks orientation to time, place or person. Which of the following the most appropriate initial course of treatment of this patient?", "answer": "Diazepam", "options": {"A": "Chlorpromazine", "B": "Clonidine", "C": "Diazepam", "D": "Haloperidol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old man", "brought", "emergency department", "son", "fever", "past day", "patients son adds", "father", "behavioral problems", "well", "bugs crawling", "skin", "morning", "insects", "Past medical history", "unremarkable", "current medications", "patient", "alcoholic", "years", "quit drinking 5 days", "patients temperature", "40", "pulse", "min", "blood pressure", "88 mm Hg", "respiratory rate", "min", "physical examination", "confused", "restless", "agitated", "lacks orientation to time", "place", "person", "following", "most appropriate initial course", "treatment", "patient"]}
{"question": "Eight weeks after starting a new weight-loss medication, a 43-year-old woman with obesity comes to the physician because of greasy diarrhea, excessive belching, and flatulence. She also complains of progressively worsening night-time vision. She has had no fever, chills, or vomiting. Physical examination shows dry, scaly skin on her extremities and face. Which of the following is the most likely mechanism of action of the drug she is taking?", "answer": "Inhibition of lipase", "options": {"A": "Stimulation of monoamine neurotransmitter release", "B": "Inhibition of serotonin reuptake", "C": "Stimulation of norepinephrine release", "D": "Inhibition of lipase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Eight weeks", "starting", "new weight-loss medication", "year old woman", "obesity", "physician", "greasy diarrhea", "excessive belching", "flatulence", "worsening night vision", "fever", "chills", "vomiting", "Physical examination shows dry", "scaly skin", "extremities", "face", "following", "most likely mechanism of action", "drug", "taking"]}
{"question": "A 70-year-old man with chronic heart failure presents to the emergency department due to difficulty in breathing. The patient is a known hypertensive for 20 years maintained on amlodipine and telmisartan. The physician notes that he is also being given a diuretic that blocks the Na+ channels in the cortical collecting tubule. Which drug is being referred to in this case?", "answer": "Triamterene", "options": {"A": "Furosemide", "B": "Hydrochlorothiazide", "C": "Triamterene", "D": "Acetazolamide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old man", "chronic heart failure presents", "emergency department due to difficulty", "breathing", "patient", "known hypertensive", "20 years maintained", "amlodipine", "telmisartan", "physician notes", "given", "diuretic", "blocks", "Na", "channels", "cortical collecting tubule", "drug", "referred to", "case"]}
{"question": "A 59-year-old man with a history of sickle cell disease presents to the emergency department for evaluation of his fever and night sweats. He is extremely lethargic and is unable to provide an adequate history to his physician. His wife noted that roughly 3 days ago, her husband mentioned that something bit him, but she cannot remember what exactly. The vital signs include blood pressure 85/67 mm Hg, pulse rate 107/min, and respiratory rate 35/min. Upon examination, the man is currently afebrile but is lethargic and pale. His spleen is surgically absent. There are some swollen bite marks on his right hand with red streaks extending to his elbow. Which of the following bites would be most concerning in this patient?", "answer": "Dog bite", "options": {"A": "Human bite", "B": "Spider bite", "C": "Fish bite", "D": "Dog bite"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["59 year old man", "history of sickle cell disease presents", "emergency department", "evaluation", "fever", "night sweats", "extremely lethargic", "unable to provide", "adequate history", "physician", "wife noted", "days", "husband", "bit", "remember", "vital signs include blood pressure 85 67 mm Hg", "pulse rate", "min", "respiratory rate 35 min", "examination", "man", "currently afebrile", "lethargic", "pale", "spleen", "surgically absent", "swollen bite marks", "right", "red streaks extending", "elbow", "following bites", "most concerning", "patient"]}
{"question": "A 30-year-old woman comes to the physician because of increasing weakness in both legs for 7 days. She also reports a tingling sensation in her legs that is exacerbated by taking a hot shower. She is sexually active with one male partner and does not use condoms. Her temperature is 37.8°C (100.1°F). Physical examination shows decreased muscle strength and clonus in both lower extremities. Patellar reflex is 4+ bilaterally and plantar reflex shows an extensor response on both sides. Abdominal reflex is absent. An MRI of the brain is shown. Which of the following findings is most likely to further support the diagnosis in this patient?", "answer": "Presence of immunoglobulin bands on cerebrospinal fluid immunofixation", "options": {"A": "Positive antibody response to cardiolipin-cholesterol-lecithin antigen in the serum", "B": "Oligodendrocytes that stain positive for polyomavirus proteins on brain biopsy", "C": "Presence of immunoglobulin bands on cerebrospinal fluid immunofixation", "D": "Identification of gram-positive cocci in groups on blood culture"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old woman", "physician", "of increasing weakness in both legs", "7 days", "reports", "tingling sensation", "legs", "exacerbated", "hot shower", "sexually active", "one male partner", "not use condoms", "temperature", "100", "Physical examination shows decreased muscle strength", "clonus", "lower extremities", "Patellar", "4", "plantar reflex shows", "extensor response", "sides", "Abdominal reflex", "absent", "MRI of", "brain", "shown", "following findings", "most likely", "further support", "diagnosis", "patient"]}
{"question": "A group of investigators is studying the association between a fire retardant chemical used on furniture and interstitial lung disease. They use hospital records to identify 50 people who have been diagnosed with interstitial lung disease. They also identify a group of 50 people without interstitial lung disease who are matched in age and geographic location to those with the disease. The participants' exposure to the chemical is assessed by surveys and home visits. Which of the following best describes this study design?", "answer": "Case-control study", "options": {"A": "Case-control study", "B": "Case series", "C": "Retrospective cohort study", "D": "Randomized controlled trial"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["A group", "investigators", "studying", "association", "fire retardant chemical used", "furniture", "interstitial lung disease", "use hospital records to", "50 people", "diagnosed", "interstitial lung disease", "a group", "50 people", "interstitial lung disease", "matched", "age", "geographic location", "disease", "participants", "exposure to", "chemical", "assessed", "surveys", "home visits", "following best", "study design"]}
{"question": "A 41-year-old man is brought to the emergency department after a suicide attempt. His wife found him on the bathroom floor with an empty bottle of medication next to him. He has a history of major depressive disorder. His only medication is nortriptyline. His pulse is 127/min and blood pressure is 90/61 mm Hg. Examination shows dilated pupils and dry skin. The abdomen is distended and there is dullness on percussion in the suprapubic region. An ECG shows tachycardia and a QRS complex width of 130 ms. In addition to intravenous fluid resuscitation, which of the following is the most appropriate pharmacotherapy?", "answer": "Sodium bicarbonate", "options": {"A": "Naloxone", "B": "Cyproheptadine", "C": "Ammonium chloride", "D": "Sodium bicarbonate"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "emergency department", "suicide attempt", "wife found", "bathroom floor", "empty bottle", "medication next to", "history of major depressive disorder", "only medication", "nortriptyline", "pulse", "min", "blood pressure", "90 61 mm Hg", "Examination shows dilated pupils", "dry skin", "abdomen", "distended", "dullness", "percussion", "suprapubic region", "ECG shows tachycardia", "QRS complex width", "ms", "intravenous", "following", "most appropriate pharmacotherapy"]}
{"question": "A 23-year-old woman presents to the hospital for elective surgery. However, due to an unexpected bleeding event, the physician had to order a blood transfusion to replace the blood lost in the surgery. After this, the patient became irritable and had difficulty breathing, suggesting an allergic reaction, which was immediately treated with epinephrine. This patient is otherwise healthy, and her history does not indicate any health conditions or known allergies. The physician suspects an immunodeficiency disorder that was not previously diagnosed. If serum is taken from this patient to analyze her condition further, which of the following would be expected?", "answer": "Low IgA, normal IgG, and IgM", "options": {"A": "High IgM, low IgA, and IgE", "B": "Low IgA, normal IgG, and IgM", "C": "High IgE, normal IgA, and IgG", "D": "Normal serum immunoglobulin values"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman presents", "hospital", "elective surgery", "unexpected bleeding event", "physician", "to order", "blood transfusion to replace", "blood lost", "surgery", "patient", "irritable", "difficulty breathing", "suggesting", "allergic reaction", "immediately treated with epinephrine", "patient", "healthy", "history", "not", "health conditions", "known allergies", "physician suspects", "immunodeficiency disorder", "not", "diagnosed", "serum", "taken", "patient to", "condition further", "following", "expected"]}
{"question": "A 21-year-old man is brought to the emergency department 30 minutes after being found unconscious in his apartment by his mother. On arrival, he is unable to provide history. The mother reports that there is no history of serious illness in the family. The patient appears drowsy and dehydrated. His temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 170/100 mm Hg. Examination shows several track marks on his forearms and large contusions over his forehead, legs, and back. There is blood coming from the mouth. The patient is catheterized and tea-colored urine is drained. Urinalysis shows:\nUrine\npH 5.8\nSpecific gravity 1.045\nBlood 3+\nGlucose 3+\nProteins 1+\nKetones 1+\nRBC none\nWBC 0-1/hpf\nUrine toxicology is positive for opiates and cocaine. Intravenous fluids and sodium nitroprusside drip are started. The patient is most likely to have which of the following?\"", "answer": "Elevated serum creatine kinase", "options": {"A": "Low serum potassium", "B": "Low blood urea nitrogen", "C": "Elevated serum calcium", "D": "Elevated serum creatine kinase"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["21-year-old man", "brought", "emergency department 30 minutes", "found unconscious", "apartment", "mother", "arrival", "unable to provide history", "mother reports", "history", "serious illness", "family", "patient appears drowsy", "dehydrated", "temperature", "pulse", "min", "blood pressure", "100 mm Hg", "Examination shows several track marks", "forearms", "large contusions", "forehead", "legs", "back", "blood", "mouth", "patient", "catheterized", "tea colored urine", "drained", "Urinalysis shows", "Urine pH", "Specific gravity", "Blood", "Glucose", "Proteins", "Ketones", "RBC", "WBC 0-1 hpf Urine toxicology", "positive", "opiates", "cocaine", "Intravenous fluids", "sodium nitroprusside drip", "started", "patient", "most likely to", "following"]}
{"question": "A 30-year-old G4P3 woman at 38 weeks gestation is admitted to the labor and delivery unit complaining of contractions every 5 minutes for the past hour. Her previous births have been via uncomplicated caesarean sections, but she wishes to attempt vaginal delivery this time. Her prenatal care is notable for gestational diabetes controlled with diet and exercise. The delivery is prolonged, but the patient's pain is controlled with epidural analgesia. She delivers a male infant with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Fundal massage is performed, but the placenta does not pass. The obstetrician manually removes the placenta, but a red mass protrudes through the vagina attached to the placenta. The patient loses 500 mL of blood over the next minute, during which her blood pressure decreases from 120/80 mmHg to 90/65 mmHg. What is the best next step in management?", "answer": "Elevate posterior fornix", "options": {"A": "Hysterectomy", "B": "Intravenous oxytocin", "C": "Elevate posterior fornix", "D": "Red blood cell transfusion"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["30 year old", "woman", "weeks", "admitted", "labor", "delivery unit", "contractions", "5 minutes", "past hour", "previous births", "uncomplicated caesarean sections", "wishes to attempt vaginal delivery", "time", "prenatal care", "notable", "gestational diabetes controlled", "diet", "exercise", "delivery", "prolonged", "patient's pain", "controlled", "epidural analgesia", "delivers", "male infant", "Apgar scores", "8", "5 minutes", "Fundal massage", "performed", "placenta", "not pass", "obstetrician manually removes", "placenta", "red mass", "vagina attached", "placenta", "patient", "500 mL", "blood", "next minute", "blood pressure decreases", "80 mmHg", "90 65 mmHg", "best next step", "management"]}
{"question": "A 42-year-old man comes to the physician to establish care. He recently moved to the area and has not been to a primary care physician for over 5 years. He has no history of serious illness, but has intermittent bilateral knee pain for which he takes 650 mg acetaminophen every other day. He is married with three children and is sexually active with his wife. During the past 10 years, he has unsuccessfully tried to lose weight. He has smoked one half pack of cigarettes daily for 15 years. About 2–3 times per week he has 1–2 glasses of wine with dinner. He is 160 cm (5 ft 3 in) tall and weighs 93 kg (205 lb); BMI is 36.3 kg/m2. Vital signs are within normal limits. On abdominal examination, the liver is palpated 2 to 3 cm below the right costal margin. Laboratory studies show:\nHemoglobin 12.6 g/dL\nPlatelet count 360,000/mm3\nHemoglobin A1c 6.3%\nSerum\nFerritin 194 ng/mL\nTotal bilirubin 0.7 mg/dL\nAlkaline phosphatase 52 U/L\nAspartate aminotransferase 92 U/L\nAlanine aminotransferase 144 U/L\nHepatitis B surface antigen Negative\nHepatitis B core IgM antibody Negative\nHepatitis B surface antibody Positive\nHepatitis C antibody Negative\nAntinuclear antibody titers 1:20 (N = < 1:60)\nSmooth muscle antibody titers Negative\nAnti-LKM1 antibody titers Negative\nTransabdominal ultrasonography shows a mildly enlarged, diffusely hyperechoic liver. Which of the following is the most likely underlying cause of these liver abnormalities?\"", "answer": "Insulin resistance", "options": {"A": "Autoimmune liver damage", "B": "Congestive hepatopathy", "C": "Insulin resistance", "D": "Acetaminophen use"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician to establish care", "recently moved to", "area", "not", "primary care physician", "over", "years", "history", "serious illness", "intermittent bilateral knee pain", "takes 650 mg acetaminophen", "day", "married", "three children", "sexually active", "wife", "past 10 years", "to", "weight", "smoked one half pack", "cigarettes daily", "years", "23 times", "week", "glasses", "wine", "dinner", "5 ft", "tall", "kg", "BMI", "36", "kg/m2", "Vital signs", "normal limits", "abdominal examination", "liver", "palpated 2", "3 cm", "right costal margin", "Laboratory studies show", "g dL", "dL", "Alanine", "antigen", "1 20", "N", "1 60", "Smooth muscle antibody titers Negative", "Transabdominal ultrasonography shows", "mildly enlarged", "hyperechoic liver", "following", "the most likely underlying cause of", "liver abnormalities"]}
{"question": "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?", "answer": "Runs posteriorly from the medial femoral condyle", "options": {"A": "Runs anteriorly from the medial femoral condyle", "B": "Runs medially from the lateral femoral condyle", "C": "Runs posteriorly from the lateral femoral condyle", "D": "Runs posteriorly from the medial femoral condyle"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "ambulance", "soccer game", "game", "to", "ball", "leg", "front", "unable to stand up", "collision", "reported severe knee", "presentation", "found to", "mild knee effusion", "Physical exam showed", "knee", "pushed", "90 degrees", "flexion", "not", "pulled", "same position", "anatomic structure", "most likely injured", "patient", "following characteristics"]}
{"question": "A 64-year-old male with a past medical history of two myocardial infarctions presents to the emergency room with shortness of breath. He notes that he stopped taking his furosemide two weeks prior, because he ran out of pills. On exam, his oxygen saturation is 78%, his lungs have crackles throughout, and jugular venous pulsation is located at the earlobe. EKG and troponin levels are normal. Which of the following is consistent with this man's pulmonary physiology?", "answer": "Increased Aa gradient, decreased surface area for diffusion, increased diffusion distance", "options": {"A": "Decreased Aa gradient, decreased surface area for diffusion, normal diffusion distance", "B": "Decreased Aa gradient, increased surface area for diffusion, decreased diffusion distance", "C": "Increased Aa gradient, normal surface area for diffusion, increased diffusion distance", "D": "Increased Aa gradient, decreased surface area for diffusion, increased diffusion distance"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year", "male", "past medical history of two myocardial infarctions presents", "emergency room", "shortness of breath", "notes", "stopped taking", "furosemide two weeks prior", "ran out", "pills", "exam", "oxygen saturation", "lungs", "crackles", "jugular venous", "earlobe", "EKG", "troponin levels", "normal", "following", "consistent with", "man's pulmonary physiology"]}
{"question": "A 50-year-old man presents to the office with complaints of fever and chills for 4 weeks. He adds that he is fatigued all the time and has generalized weakness. He has drenching night sweats and has had 2 episodes of non-bilious vomiting over the past few days. He traveled to the Netherlands for 4 days a month ago. His symptoms started a few days after he returned home. Laboratory testing revealed the following:\nHemoglobin 11.2 g/dL\nHematocrit 29%\nLeukocyte count 2,950/mm3\nNeutrophils  59%\nBands  3%\nEosinophils 1%\nBasophils  0%\nLymphocytes 31%\nMonocytes  4%\nPlatelet count  60,000/mm3\nUnconjugated bilirubin 12 mg/dL\nAlanine aminotransferase 200 IU/L\nAspartate aminotransferase 355 IU/L\nThe peripheral blood smear showed basophilic ring- and pear-shaped structures inside many red cells and extracellular basophilic rings on Wright-Giemsa staining. Further evaluation revealed parasitemia and a few schistocytes, poikilocytes, and merozoites in tetrad formation. The findings are most consistent with which diagnosis?", "answer": "Babesiosis", "options": {"A": "Malaria", "B": "Babesiosis", "C": "Tuberculosis", "D": "Lyme disease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["50 year old man presents", "office", "complaints", "fever", "chills", "weeks", "adds", "fatigued", "time", "generalized weakness", "drenching night", "2 episodes of non bilious vomiting", "past", "days", "traveled", "Netherlands", "4 days", "month", "symptoms started", "few days", "returned home", "Laboratory testing revealed", "following", "Hemoglobin", "Hematocrit", "Leukocyte count", "mm3 Neutrophils", "59", "Bands", "Basophils", "0", "Lymphocytes", "4", "Platelet count", "60", "Unconjugated bilirubin 12", "Alanine aminotransferase", "IU/L Aspartate aminotransferase", "peripheral blood smear showed basophilic ring", "pear-shaped structures", "red cells", "extracellular basophilic rings", "Wright-Giemsa staining", "Further evaluation revealed parasitemia", "few schistocytes", "poikilocytes", "merozoites", "formation", "findings", "most consistent with", "diagnosis"]}
{"question": "A 41-year-old woman presents with shortness of breath that is worse when she lies on her left side. About 10 days ago, she had an episode of unexplained loss of consciousness. Past medical history is negative and family history is irrelevant. Clinical examination shows a diastolic murmur, which is prominent when she lies on her left side. Jugular venous distention is present, and chest examination reveals fine crackles that do not clear with coughing. Chest X-ray shows pulmonary congestion, and 2-dimensional echocardiogram shows a mass in the left atrium attached to the atrial septum. Which of the following is the most likely diagnosis?", "answer": "Atrial myxoma", "options": {"A": "Rheumatic fever", "B": "Innocent murmur", "C": "Non-bacterial thrombotic endocarditis", "D": "Atrial myxoma"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "shortness of breath", "worse", "left side", "10 days", "episode of unexplained loss", "consciousness", "Past medical history", "negative", "family history", "Clinical examination shows", "diastolic murmur", "prominent", "left side", "Jugular venous distention", "present", "chest examination reveals fine crackles", "not clear", "coughing", "Chest X-ray shows pulmonary congestion", "2-dimensional echocardiogram shows", "mass", "left atrium attached", "atrial septum", "following", "most likely diagnosis"]}
{"question": "A 25-year-old man presents with painless swelling of the neck for the past week. He reports no recent fevers, night sweats, or weight loss. His past medical history is significant for human immunodeficiency virus (HIV) infection, which was diagnosed last year. He also experienced a head trauma 5 years ago, which has been complicated by residual seizures. His only medication is daily phenytoin, which was restarted after he had a seizure 3 months ago. His temperature is 36.8℃ (98.2℉). On physical examination, multiple non-tender lymph nodes, averaging 2 cm in diameter, are found to be palpable in the anterior and posterior triangles of the neck bilaterally. No other lymphadenopathy is noted. The remainder of the physical exam is unremarkable. Laboratory studies show the following:\nHemoglobin 14 g/dL\nLeukocyte count 8000/mm3 with a normal differential\nPlatelet count 250,000/mm3\nErythrocyte sedimentation rate 40 mm/h\nAn excisional biopsy of one of the cervical lymph nodes is performed. The histopathologic analysis is shown in the image. Which of the following is the most likely diagnosis in this patient?", "answer": "Classical Hodgkin’s lymphoma (HL)", "options": {"A": "Acute lymphoid leukemia (ALL)", "B": "Classical Hodgkin’s lymphoma (HL)", "C": "HIV lymphadenopathy", "D": "Phenytoin-induced adenopathy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "painless swelling of the neck", "past week", "reports", "recent fevers", "night sweats", "weight loss", "past medical history", "significant", "human immunodeficiency virus", "infection", "diagnosed last year", "experienced", "head trauma 5 years", "complicated", "residual seizures", "only medication", "daily phenytoin", "restarted", "seizure", "months", "temperature", "36", "98", "physical examination", "multiple non tender lymph nodes", "averaging 2", "diameter", "found to", "palpable", "anterior", "posterior triangles of", "neck", "lymphadenopathy", "noted", "physical exam", "unremarkable", "Laboratory studies show", "following", "Hemoglobin", "g Leukocyte count 8000 mm3", "normal differential Platelet count", "mm3 Erythrocyte sedimentation rate 40 mm/h", "excisional one", "cervical", "performed", "histopathologic analysis", "shown", "image", "following", "most likely diagnosis", "patient"]}
{"question": "A 67-year-old woman presents to her primary care physician for urinary incontinence. She has been waking up every morning with her underwear soaked in urine. She notices that at work if she does not take regular bathroom breaks her underwear will have some urine in it. She urinates 5 to 11 times per day but she claims it is a small volume. Her current medications include lisinopril, metformin, insulin, aspirin, atorvastatin, sodium docusate, and loratadine. Her temperature is 98.2°F (36.8°C), blood pressure is 167/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for decreased pinprick sensation in the lower extremities and a systolic murmur along the right upper sternal border. Which of the following is the best treatment for this patient?", "answer": "Bethanechol and intermittent straight catheterization", "options": {"A": "Bethanechol and intermittent straight catheterization", "B": "Bethanechol during the day and oxybutynin at night", "C": "No recommendations needed", "D": "Reduce fluid intake and discontinue diuretics"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["67 year old woman presents", "primary care physician", "urinary incontinence", "waking up", "morning", "underwear soaked", "urine", "work", "not take regular bathroom breaks", "underwear", "urine", "5", "times", "day", "small volume", "current medications include lisinopril", "metformin", "insulin", "aspirin", "atorvastatin", "sodium docusate", "loratadine", "temperature", "98", "36", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "decreased pinprick sensation", "lower extremities", "systolic murmur", "right upper sternal border", "following", "best treatment", "patient"]}
{"question": "A 55-year-old man presents into the emergency department with a severe cough and difficulty breathing. He says that he finds himself out of breath after taking a few steps, and has to sit down and rest, in order to continue. He also says that, at night, he has the greatest difficulty in breathing and usually uses at least 3 pillows to sleep comfortably. He mentions a cough that appears only at night, but which is persistent enough to wake him up from sleep. He mentions that he has had a ‘heart attack’ 5 years ago. He also says that he continues to consume alcohol on a regular basis even though his doctor has advised against it. He has brought his lab reports which he had recently got done on the suggestions of his family doctor. An electrocardiogram (ECG) and a chest X-ray are found. Which of the following is the next step in this patient’s management?", "answer": "Echocardiogram", "options": {"A": "Computed Tomography (CT)", "B": "Echocardiogram", "C": "Stress test", "D": "Cardiac biopsy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["55 year old man presents", "emergency department", "severe cough", "difficulty breathing", "finds", "out of breath", "few steps", "to sit down", "rest", "order to continue", "night", "greatest difficulty", "breathing", "usually uses", "pillows to sleep", "cough", "appears only", "night", "persistent", "to wake", "sleep", "heart attack", "years", "continues to", "alcohol", "regular basis", "doctor", "brought", "lab reports", "recently got done", "suggestions of", "family doctor", "electrocardiogram", "chest X-ray", "found", "following", "next step", "patients management"]}
{"question": "A 2-day-old boy delivered at 34 weeks gestation is found to have a murmur on routine exam. He is lying supine and is not cyanotic. He has a pulse of 195/min, and respirations of 59/min. He is found to have a nonradiating continuous machine-like murmur at the left upper sternal border. S1 and S2 are normal. The peripheral pulses are bounding. Assuming this patient has no other cardiovascular defects, what is the most appropriate treatment?", "answer": "Indomethacin", "options": {"A": "Indomethacin", "B": "Thiazide diuretic", "C": "Aspirin", "D": "Penicillin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2-day old boy delivered", "weeks gestation", "found to", "murmur", "routine exam", "lying supine", "not cyanotic", "pulse", "min", "respirations", "59 min", "found to", "continuous machine", "murmur", "left upper sternal border", "S1", "S2", "normal", "peripheral pulses", "bounding", "patient", "cardiovascular defects", "most appropriate treatment"]}
{"question": "A 12-year-old girl is brought to your psychiatry office by her parents, who are concerned that she has not made any friends since starting middle school last year. The girl tells you that she gets nervous around other children, as she cannot tell what they are feeling, when they are joking, or what she has in common with them. Her teachers describe her as “easily distracted” and “easily upset by change.” When asked about her hobbies and interests, she states that “marine biology” is her only interest and gives you a 15-minute unsolicited explanation of how to identify different penguin species. Mental status exam is notable for intense eye contact, flat affect, and concrete thought process. Which of the following is true regarding this child’s disorder?", "answer": "Boys are more commonly affected than girls", "options": {"A": "Boys are more commonly affected than girls", "B": "Impaired attention is a key feature of the disorder", "C": "Intellectual disability is a key feature of the disorder", "D": "Typical age of onset is 3-5 years of age"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "psychiatry office", "parents", "concerned", "not made", "friends", "starting middle school", "year", "girl", "gets nervous", "children", "feeling", "joking", "in common", "teachers", "easily", "easily upset", "change", "hobbies", "interests", "states", "marine biology", "only interest", "gives", "minute", "explanation", "to", "different penguin species", "Mental status exam", "notable", "intense eye contact", "flat affect", "concrete thought process", "following", "true", "childs disorder"]}
{"question": "Four days after admission to the hospital for pneumonia, a 68-year-old woman develops abdominal pain and watery, foul-smelling diarrhea. Current medications include intravenous ceftriaxone and oral azithromycin. Stool cultures grow gram-positive, anaerobic rods. She is moved to an isolated hospital room. Sterilization with which of the following agents is most likely to prevent transmission of this pathogen to the next patient who will occupy her room?", "answer": "Chlorine-based solution", "options": {"A": "Chlorine-based solution", "B": "Iodine-based solution", "C": "Isopropanol-based solution", "D": "Quaternary amine-based solution"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Four days", "admission", "hospital", "pneumonia", "68 year old woman", "abdominal pain", "watery", "smelling diarrhea", "Current medications include intravenous ceftriaxone", "oral azithromycin", "Stool cultures", "gram-positive", "anaerobic rods", "moved to", "isolated hospital room", "Sterilization", "following agents", "most likely to prevent transmission", "pathogen", "next patient", "room"]}
{"question": "A 1-month-old girl is brought to the pediatrician by her parents. They are concerned that she becomes lethargic and irritated between meals. They found that feeding her often with small servings helps. She was born at 39 weeks via spontaneous vaginal delivery and is meeting all developmental milestones. Her mother has one brother that occasionally requires blood transfusions. Today, her blood pressure is 55/33 mm Hg, his heart rate is 120/min, respiratory rate is 40/min, and temperature of 37.0°C (98.6°F). On physical exam, the infant is irritated. She is slightly jaundiced. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Her blood work shows normocytic anemia with elevated reticulocyte count and decreased haptoglobin. Sickle cell anemia and other hemoglobinopathies are also ruled out. A Coombs test is negative. Red blood cell osmotic fragility gap is normal. The physician determined that these findings are related to an enzyme deficiency. Which of the following allosterically inhibits this enzyme?", "answer": "Alanine", "options": {"A": "Alanine", "B": "Adenosine monophosphate", "C": "Fructose 1,6-bisphosphate", "D": "Fructose 2,6-bisphosphate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old girl", "brought", "pediatrician", "parents", "concerned", "lethargic", "meals", "found", "feeding", "often", "small servings helps", "born", "weeks", "spontaneous vaginal delivery", "meeting", "developmental milestones", "mother", "one brother", "occasionally", "blood transfusions", "Today", "blood pressure", "55", "mm Hg", "heart rate", "min", "respiratory rate", "40 min", "temperature", "98", "physical exam", "infant", "slightly jaundiced", "heart", "regular rate", "rhythm", "lungs", "clear", "auscultation", "blood work shows normocytic anemia", "elevated reticulocyte count", "decreased haptoglobin", "Sickle cell anemia", "hemoglobinopathies", "ruled out", "Coombs test", "negative", "Red blood cell osmotic fragility gap", "normal", "physician", "findings", "related", "enzyme deficiency", "following", "inhibits", "enzyme"]}
{"question": "A 4-year-old boy presents for a routine checkup. The patient’s parents say he was doing well until a few weeks ago at which time he started to complain of daily abdominal cramps and occasional muscle pains. His mother also noticed that he has been less active than usual. The parents deny any complaints of headaches or convulsions. The family lives together in a house built in 1950. The patient’s temperature is 36.8°C (98.2°F), blood pressure is 100/70 mm Hg, pulse is 100/min and respirations are 20/min. Abdominal exam shows mild diffuse tenderness to palpation and normal bowel sounds. The patient’s height, weight, and head circumference are normal. Laboratory results are as follows:\nHemoglobin 7 g/dL\nMean corpuscular volume (MCV) 72\nLead level (capillary blood) 15 mcg/dL\nLead level (venous blood) 60 mcg/dL\nFindings on a peripheral blood smear are shown in the image. Which of the following is the best treatment option for this patient?", "answer": "Dimercaptosuccinic acid (DMSA), also known as succimer", "options": {"A": "Trientine", "B": "Calcium disodium edetate (EDTA)", "C": "Penicillamine", "D": "Dimercaptosuccinic acid (DMSA), also known as succimer"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy presents", "routine checkup", "patients parents", "well", "weeks", "time", "started to", "daily abdominal cramps", "occasional muscle pains", "mother", "less active than usual", "parents deny", "complaints", "headaches", "convulsions", "family lives together", "house built", "patients temperature", "36", "98", "blood pressure", "100 70 mm Hg", "pulse", "100 min", "respirations", "20 min", "Abdominal exam shows mild diffuse tenderness", "palpation", "normal bowel sounds", "patients height", "weight", "head circumference", "normal", "Laboratory results", "follows", "Hemoglobin", "g/dL Mean corpuscular volume", "72 Lead", "capillary blood", "15 mcg/dL Lead level", "venous blood", "60 mcg/dL Findings", "peripheral blood smear", "shown", "image", "following", "best treatment", "patient"]}
{"question": "A 39-year-old woman with poorly controlled systemic lupus erythematosus (SLE) presents to her rheumatologist for a follow-up visit. She has had intermittent myalgias, arthralgias, fatigue, and skin rashes over the past 10 years that have acutely worsened over the past year. She works as a school teacher but reports that she has had to miss several days of work due to her symptoms. She has been on hydroxychloroquine for several years but does not feel that it is adequately controlling her symptoms. She does not smoke or drink alcohol. Her temperature is 99.2°F (37.3°C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 18/min. On exam, she is well-appearing and in no acute distress. She has erythematous, raised plaques with keratotic scaling and follicular plugging on her hands. The physician decides to trial the patient on low-dose prednisone to better control her symptoms. At 2 months of follow-up, she reports that her flares have subsided and she has been able to return to work full-time. If this patient continues this medication regimen, she will be at an elevated risk for developing which of the following?", "answer": "Femoral neck fracture", "options": {"A": "Femoral neck fracture", "B": "Femoral shaft fracture", "C": "Osgood-Schlatter disease", "D": "Proximal phalanx fracture"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "poorly controlled systemic lupus erythematosus", "presents", "rheumatologist", "follow-up visit", "intermittent myalgias", "arthralgias", "fatigue", "skin rashes", "past 10 years", "worsened", "past year", "works", "school teacher", "reports", "to miss several days", "work", "symptoms", "hydroxychloroquine", "several years", "not feel", "controlling", "symptoms", "not smoke", "drink alcohol", "temperature", "99", "3C", "blood pressure", "75 mmHg", "pulse", "80 min", "respirations", "min", "exam", "well appearing", "acute distress", "erythematous", "raised plaques", "keratotic scaling", "follicular plugging", "hands", "physician", "trial", "patient", "low-dose prednisone", "better control", "symptoms", "months", "follow-up", "reports", "flares", "able to return to work full-time", "patient continues", "medication regimen", "elevated risk", "following"]}
{"question": "A 40-year-old woman presents with severe shortness of breath. The patient is unable to provide a history due to her breathing difficulties. The patient’s roommate says that she came home and found her in this state. She also says that they both occasionally take sleeping pills to help them fall asleep. Physical examination reveals an obese female, dyspneic with diminished chest wall movements. The patient’s A-a gradient is calculated to be 10 mm Hg. Which of the following most likely accounts for this patient’s symptoms?", "answer": "Alveolar hypoventilation", "options": {"A": "Alveolar hypoventilation", "B": "Impaired gas diffusion", "C": "Left-to-right blood shunt", "D": "Right-to-left blood shunt"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old woman presents", "severe shortness of breath", "patient", "unable to provide", "history due to", "breathing difficulties", "patients roommate", "home", "found", "state", "occasionally take sleeping pills to help", "fall asleep", "Physical examination reveals", "obese female", "dyspneic", "diminished chest wall movements", "patients", "gradient", "calculated to", "10 mm Hg", "following", "likely accounts", "patients symptoms"]}
{"question": "A 74-year-old woman is brought to her primary care doctor by her adult son. The son says she has been very difficult at home and is \"losing it\". He seems very frustrated about her diminishing ability to take care of herself the way she used to and no longer thinks he can trust her watching his children. At her last visit you noted mild cognitive impairment. Today, she appears withdrawn and hesitates to make eye-contact with you. She lets her son do most of the talking. Which of the following is the most appropriate next step?", "answer": "Ask the son to step out so you can speak with the patient alone", "options": {"A": "Discuss with the son the challenges of having a parent with dementia", "B": "Complete a mini-mental exam", "C": "Assess the patient's risk for depression", "D": "Ask the son to step out so you can speak with the patient alone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["74 year old woman", "brought", "primary care doctor", "adult son", "son", "very difficult", "home", "very frustrated", "diminishing ability to take care", "used", "longer thinks", "trust", "watching", "children", "last visit", "noted mild cognitive impairment", "Today", "appears withdrawn", "to make eye-contact", "lets", "son", "most", "talking", "following", "most appropriate next step"]}
{"question": "An investigator is studying the effects of different gastrointestinal regulatory substances. A healthy subject is asked to eat a meal at hour 0, and the pH of stomach contents and rate of stomach acid secretions are measured over the next 4 hours. Results of the study are shown. Which of the following mechanisms most likely contributes to the changes seen at point D in the graph?", "answer": "Increased activity of D cells", "options": {"A": "Increased vagal stimulation", "B": "Increased activity of D cells", "C": "Increased activity of enterochromaffin-like cells", "D": "Increased activity of I cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "effects", "different gastrointestinal regulatory substances", "healthy subject", "to eat", "meal", "hour 0", "pH", "stomach contents", "rate", "stomach acid secretions", "measured", "next", "hours", "Results", "study", "shown", "following mechanisms", "likely contributes", "changes seen", "point", "graph"]}
{"question": "A 45-year-old woman comes to the physician with a lump on her throat that has steadily increased in size over the past 5 months. She does not have difficulties swallowing, dyspnea, or changes in voice. Examination shows a 3-cm, hard swelling on the left side of her neck that moves with swallowing. There is no cervical or axillary lymphadenopathy. The remainder of the examination shows no abnormalities. Thyroid functions tests are within the reference range. Ultrasound of the neck shows an irregular, hypoechogenic mass in the left lobe of the thyroid. A fine-needle aspiration biopsy is inconclusive. The surgeon and patient agree that the most appropriate next step is a diagnostic lobectomy and isthmectomy. Surgery shows a 3.5-cm gray tan thyroid tumor with invasion of surrounding blood vessels, including the veins. The specimen is sent for histopathological examination. Which of the following is most likely to be seen on microscopic examination of the mass?", "answer": "Capsular invasion", "options": {"A": "Undifferentiated giant cells", "B": "Capsular invasion", "C": "Infiltration of atypical lymphoid tissue", "D": "Orphan Annie nuclei\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "lump", "throat", "increased in size", "past", "months", "not", "difficulties swallowing", "dyspnea", "changes in voice", "Examination shows", "3", "hard", "the left side", "neck", "moves", "swallowing", "cervical", "axillary lymphadenopathy", "examination shows", "abnormalities", "Thyroid functions tests", "the reference range", "Ultrasound of", "neck shows", "irregular", "mass", "left lobe", "thyroid", "fine-needle aspiration biopsy", "inconclusive", "surgeon", "patient agree", "most appropriate next step", "diagnostic lobectomy", "isthmectomy", "Surgery shows", "3.5", "gray tan thyroid", "invasion of surrounding blood vessels", "including", "veins", "specimen", "sent", "histopathological examination", "following", "most likely to", "seen", "microscopic examination", "mass"]}
{"question": "A 53-year-old female patient comes to the physician’s office for her annual check-up visit. She has no complaints and her past medical history is notable for diabetes and hypertension. During this visit, the patient undergoes screening procedures per guidelines including a mammogram. On the screening mammogram a spiculated, irregular mass is found on the left breast. Further diagnostic mammography and biopsy reveal ductal adenocarcinoma of the breast in the upper outer quadrant of the left breast. Which of the following is the most important factor in determining this patient’s prognosis?", "answer": "Tumor stage", "options": {"A": "Tumor grade", "B": "Tumor stage", "C": "Age", "D": "Location of the tumor on the breast"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old female patient", "physicians office", "annual check-up visit", "complaints", "past medical history", "notable", "diabetes", "hypertension", "visit", "patient", "screening procedures", "guidelines including", "mammogram", "screening mammogram", "spiculated", "irregular mass", "found", "left breast", "Further diagnostic mammography", "biopsy reveal ductal adenocarcinoma of the breast", "upper outer quadrant of", "left breast", "following", "most important factor", "determining", "patients prognosis"]}
{"question": "A 2-month-old girl is brought to the pediatrician by her concerned father. He states that ever since her uncomplicated delivery she has failed to gain weight, has had chronic diarrhea, and has had multiple bacterial and viral infections. During the course of the workup, an absent thymic shadow is noted and a lymph node biopsy demonstrates the absence of germinal centers. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Adenosine deaminase deficiency", "options": {"A": "Defect in ATM gene", "B": "Adenosine deaminase deficiency", "C": "NADPH oxidase deficiency", "D": "Defect in BTK gene"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["2 month old girl", "brought", "pediatrician", "father", "states", "ever", "uncomplicated delivery", "failed to gain weight", "chronic diarrhea", "multiple bacterial", "viral infections", "course", "workup", "absent thymic shadow", "noted", "lymph node biopsy demonstrates", "absence", "germinal centers", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 1-year-old boy is brought to the clinic by his parents for a regular check-up. His weight, height, and head size were found to be in the lower percentile ranges on standard growth curves. His hair is tangled and has a dry, brittle texture. Genetic testing reveals that the patient has a connective tissue disorder caused by impaired copper absorption and transport. The patient’s disorder is caused by a mutation in which of the following genes?", "answer": "ATP7A", "options": {"A": "ATP7A", "B": "COL5A1", "C": "FBN1", "D": "ATP7B"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "clinic", "parents", "regular check-up", "weight", "height", "head size", "found to", "lower percentile ranges", "standard growth curves", "hair", "dry", "brittle texture", "Genetic testing reveals", "patient", "connective tissue disorder caused", "impaired copper absorption", "transport", "patients disorder", "caused", "mutation", "following genes"]}
{"question": "A 15-year-old girl is brought to the physician because she has not had a menstrual period. There is no personal or family history of serious illness. She is 165 cm (5 ft 5 in) tall and weighs 57 kg (125 lb); BMI is 21 kg/m2. Vital signs are within normal limits. Examination of the breasts shows a secondary mound formed by the nipple and areola. Pubic hair is sparse and lightly pigmented. Abdominal examination shows bilateral firm, nontender inguinal masses. Pelvic examination shows a blind-ended vaginal pouch. Ultrasonography does not show a uterus or ovaries. Which of the following is the most appropriate treatment for this patient's condition?", "answer": "Gonadectomy", "options": {"A": "Gonadectomy", "B": "Testosterone therapy", "C": "Vaginal dilatory therapy", "D": "Prednisolone therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "physician", "not", "menstrual period", "personal", "family history", "serious illness", "5 ft 5", "tall", "57 kg", "BMI", "kg/m2", "Vital signs", "normal limits", "Examination of", "breasts shows", "secondary", "formed", "nipple", "areola", "Pubic hair", "lightly pigmented", "Abdominal examination shows bilateral firm", "nontender inguinal masses", "Pelvic examination shows", "blind ended vaginal pouch", "Ultrasonography", "not show", "uterus", "ovaries", "following", "most appropriate treatment", "patient's condition"]}
{"question": "A 51-year-old man presents the emergency room with chest pain. He mentions that the pain started several hours ago and radiates to his left neck and shoulder. He also mentions that he has some difficulty in breathing. He says that he has had similar chest pains before, but nothing seemed to be wrong at that time. He was diagnosed with high cholesterol during that episode and was prescribed medication. He also has a 3-year history of gastritis. The blood pressure is 130/80 mm Hg, respirations are 18/min, and the pulse is 110/min. He seems a little anxious. The physical examination reveals no significant abnormalities. An ECG shows slight changes in the leads. His physician talks to him about the benefits of taking low-dose aspirin daily. Which of the following would be a contraindication to the use of aspirin in this patient?", "answer": "Gastritis", "options": {"A": "ECG changes", "B": "Hypercholesterolemia", "C": "Gastritis", "D": "Increased pulse rate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "emergency room", "chest pain", "pain started several hours", "radiates", "left neck", "shoulder", "difficulty", "breathing", "similar chest pains", "to", "wrong", "time", "diagnosed", "high cholesterol", "episode", "prescribed medication", "3 year history of gastritis", "blood pressure", "80 mm Hg", "respirations", "min", "pulse", "min", "little anxious", "physical examination reveals", "significant abnormalities", "ECG shows slight changes", "leads", "physician talks", "benefits", "low-dose aspirin daily", "following", "contraindication", "use of aspirin", "patient"]}
{"question": "A 45-year-old woman presents to the physician for a follow-up visit. She has no specific complaints at this visit however, she has noticed that she is more tired than usual these days. At first, she ignored it and attributed it to stress but she feels weaker each week. She is sometimes out of breath while walking for long distances or when she is involved in strenuous physical activity. She was diagnosed with rheumatoid arthritis 3 years ago and has since been on medication to assist with her pain and to slow down disease progression. Her temperature is 37.0°C (98.6°F), the respiratory rate is 15/min, the pulse is 107/min, and the blood pressure is 102/98 mm Hg. On examination, you notice thinning hair and mildly cool extremities with flattened nail beds. A complete blood count and iron studies are ordered. Which of the following is most likely to show up on her iron profile?", "answer": "Decreased iron-binding capacity", "options": {"A": "Increased iron-binding capacity", "B": "Low ferritin levels", "C": "Decreased iron-binding capacity", "D": "Normal iron-binding capacity"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physician", "follow-up visit", "specific complaints", "visit", "more tired", "usual", "days", "first", "ignored", "attributed", "stress", "feels weaker", "week", "sometimes out of breath", "walking", "long distances", "involved", "strenuous physical activity", "diagnosed", "rheumatoid arthritis", "years", "since", "on medication to assist", "pain", "slow down disease progression", "temperature", "98", "respiratory rate", "min", "pulse", "min", "blood pressure", "98 mm Hg", "examination", "thinning hair", "mildly cool extremities", "flattened nail beds", "complete blood count", "iron studies", "ordered", "following", "most likely to show", "iron profile"]}
{"question": "An 89-year-old woman is brought to the emergency department by her husband because of diarrhea and weakness for 4 days. She has 2–3 loose stools every day. She has also had 3 episodes of vomiting. She complains of a headache and blurry vision. Three weeks ago, she returned from a cruise trip to the Bahamas. She has congestive heart failure, atrial fibrillation, age-related macular degeneration, type 2 diabetes mellitus, and chronic renal failure. Current medications include warfarin, metoprolol, insulin, digoxin, ramipril, and spironolactone. Her temperature is 36.7°C (98°F), pulse is 61/min, and blood pressure is 108/74 mm Hg. The abdomen is soft, and there is diffuse, mild tenderness to palpation. Laboratory studies show:\nHemoglobin 12.9 g/dL\nLeukocyte count 7200/mm3\nPlatelet count 230,000/mm3\nSerum\nNa+ 137 mEq/L\nK+ 5.2 mEq/L\nGlucose 141 mg/dL\nCreatinine 1.3 mg/dL\nWhich of the following is the most appropriate next step in management?\"", "answer": "Measure serum drug concentration", "options": {"A": "Perform hemodialysis", "B": "Perform C. difficile toxin assay", "C": "Measure serum drug concentration", "D": "Administer oral activated charcoal"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "emergency department", "husband", "diarrhea", "weakness", "4 days", "23 loose stools", "day", "3 episodes of vomiting", "headache", "blurry vision", "Three weeks", "returned", "trip", "Bahamas", "congestive heart failure", "atrial fibrillation", "age-related macular degeneration", "type 2 diabetes mellitus", "chronic renal failure", "Current medications include warfarin", "metoprolol", "insulin", "digoxin", "ramipril", "spironolactone", "temperature", "36", "pulse", "61 min", "blood pressure", "74 mm Hg", "abdomen", "soft", "diffuse", "mild tenderness", "palpation", "Laboratory studies show", "Hemoglobin", "g", "Leukocyte", "mm3 Platelet count", "Na", "137", "L", "5 2", "mg", "mg", "following", "most appropriate next step", "management"]}
{"question": "A 45-year-old woman is brought to the emergency department by her husband due to upper abdominal pain, nausea, and vomiting for the past couple of hours. She had similar episodes in the past, which were often precipitated by food but resolved spontaneously. Her temperature is 38.3°C (101.0°F), heart rate is 96/min, blood pressure is 118/76 mm Hg, and respiratory rate is 16/min. Physical examination reveals tenderness over the right upper quadrant that is severe enough to make her stop breathing when deeply palpated in the area. Lab results show:\nLeukocyte count 18,000/mm3 with 79% neutrophils\nAspartate aminotransferase 67 IU/L\nAlanine aminotransferase 71 IU/L\nSerum amylase 46 U/L\nSerum Lipase 55 U/L\nSerum calcium 8.9 mg/dL\nUltrasonography of the abdomen is shown below. During the ultrasound exam, the patient complains of tenderness when the probe presses down on her right upper quadrant. Which of the following is the most likely cause of her pain?", "answer": "Acute calculous cholecystitis", "options": {"A": "Acute calculous cholecystitis", "B": "Acute acalculous cholecystitis", "C": "Acute pancreatitis", "D": "Ascending cholangitis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "husband due to upper abdominal pain", "nausea", "vomiting", "past couple", "hours", "similar episodes", "past", "often precipitated", "food", "resolved", "temperature", "3C", "heart rate", "96 min", "blood pressure", "76 mm Hg", "respiratory rate", "min", "Physical examination reveals tenderness", "right upper quadrant", "severe", "to make", "stop breathing", "deeply palpated", "area", "Lab results show", "Leukocyte count", "mm3", "Aspartate aminotransferase", "IU/L Alanine aminotransferase", "amylase", "U", "calcium", "mg", "Ultrasonography", "abdomen", "shown", "ultrasound exam", "patient", "tenderness", "probe", "right upper quadrant", "following", "most likely cause", "pain"]}
{"question": "A mother brings her 18-year-old daughter to your office because she has not menstruated yet. They recently immigrated from another country, and do not have any previous medical records. The adolescent girl looks relatively short, but otherwise looks healthy. She has no complaints except for mild intermittent lower abdominal pain for the past year. On physical examination, vitals are within normal limits. There is the presence of axillary hair, breast development, and pubic hair at Tanner stage 5. You explain to the mother and the patient that you need to perform a complete vaginal examination, however, both of them declined the procedure and would prefer that lab test be performed. Her labs are significant for the following:\nFSH 7 mIU/mL\nNormal values:  \n   Follicular phase 3.1 – 7.9 mIU/mL\n   Ovulation peak 2.3 – 18.5 mIU/mL\n   Luteal phase 1.4 – 5.5 mIU/mL\n   Postmenopausal 30.6 – 106.3 mIU/mL\nEstradiol 28 pg/mL\nNormal values:  \n   Mid-follicular phase 27 – 123 pg/mL\n   Periovulatory 96 – 436 pg/mL\n   Mid-luteal phase 49 – 294 pg/mL\n   Postmenopausal 0 – 40 pg/mL\nTestosterone 52 ng/dL, 40 – 60 ng/dL\nWhat is the most likely diagnosis of this patient?", "answer": "Muellerian agenesis", "options": {"A": "Muellerian agenesis", "B": "Hyperprolactinemia", "C": "Turner syndrome", "D": "Androgen insensitivity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["mother", "year old daughter", "office", "not", "recently", "country", "not", "previous medical records", "adolescent girl looks", "short", "looks healthy", "complaints", "mild intermittent lower abdominal pain", "past year", "physical examination", "normal limits", "presence", "axillary hair", "breast development", "pubic hair", "Tanner stage 5", "mother", "patient", "need to perform", "complete vaginal examination", "procedure", "lab test", "performed", "labs", "significant", "following", "mIU/mL Normal values", "Follicular phase", "mL", "Ovulation peak", "mL", "Luteal phase", "Postmenopausal", "Estradiol", "pg", "Normal values", "Mid follicular 27", "pg/mL", "96", "luteal phase", "Postmenopausal 0", "40", "Testosterone", "ng/dL", "40", "60 ng/dL", "most likely diagnosis", "patient"]}
{"question": "A 62-year-old woman with a pancreatic insulinoma is being prepared for a laparoscopic enucleation of the tumor. After induction of general anesthesia, preparation of a sterile surgical field, and port placement, the surgeon needs to enter the space posterior to the stomach to access the pancreatic tumor. Which of the following ligaments must be cut in order to access this space?", "answer": "Gastrohepatic ligament", "options": {"A": "Phrenoesophageal ligament", "B": "Gastrohepatic ligament", "C": "Phrenicocolic ligament", "D": "Ligamentum venosum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old woman", "pancreatic insulinoma", "prepared", "laparoscopic enucleation", "tumor", "induction of general anesthesia", "preparation", "sterile surgical field", "port placement", "surgeon needs to enter", "space posterior", "stomach to access", "pancreatic tumor", "following ligaments", "cut", "order to access", "space"]}
{"question": "A 55-year-old man is brought to the emergency room by his wife for severe abdominal pain for the past 1 hour. He is unable to give more information about the nature of his pain. His wife says that he has peptic ulcer disease and is being treated with antacids without a good response. She adds that he vomited repeatedly  in the last couple of hours, his vomitus being brown/red in color. His temperature is 98.6°F (37°C), respiratory rate is 16/min, pulse is 97/min, and blood pressure is 100/68 mm Hg. A physical exam reveals a tense abdomen with a board like rigidity and positive rebound tenderness. An erect abdominal x-ray is ordered. Which of the following is the most likely diagnosis?", "answer": "Perforated gastric peptic ulcer", "options": {"A": "Duodenal peptic ulcer", "B": "Gastric peptic ulcer", "C": "Pancreatitis", "D": "Perforated gastric peptic ulcer"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["55 year old man", "brought", "emergency room", "wife", "severe abdominal", "past", "hour", "unable to give more information", "nature", "pain", "wife", "peptic ulcer disease", "treated with antacids", "good response", "adds", "vomited repeatedly", "couple", "hours", "vomitus", "brown red", "color", "temperature", "98", "respiratory rate", "min", "pulse", "97 min", "blood pressure", "100 68 mm Hg", "physical exam reveals", "tense abdomen", "board", "rigidity", "positive rebound tenderness", "erect abdominal x-ray", "ordered", "following", "most likely diagnosis"]}
{"question": "A 62-year-old man presents with episodes of palpitations for the past 3 weeks. He says that he has episodes where he feels his heart is ‘racing and pounding’, lasting 1–2 hours on average. Initially, he says the episodes would happen 1–2 times per week but now happen almost every day. This last episode has been constant for the past 2 days. He denies any seizure, loss of consciousness, dizziness, chest pain, or similar symptoms in the past. His past medical history is significant for an ischemic stroke of the right anterior cerebral artery 1 month ago, status post intravenous (IV) tissue plasminogen activator (tPA) with still some residual neurologic impairment, and long-standing gastroesophageal reflux secondary to a hiatal hernia, managed medically. The patient reports a 15-pack-year smoking history, but no alcohol or recreational drug use. The vital signs include: temperature 37.0°C (98.6°F), blood pressure 100/70 mm Hg, pulse 105/min, and respiratory rate 16/min. On physical examination, muscle strength in the lower extremities is 4/5 on the left and 5/5 on the right, along with sensory loss on the left, all of which is improved from his previous exam 3 weeks ago. There is a loss of the left half of the visual field bilaterally which is stable from the previous exam. Cardiac examination is significant for a new-onset irregular rate and rhythm. No rubs, thrills or murmurs. A noncontrast computed tomography (CT) scan shows evidence of an area of infarction in the vicinity of the right anterior cerebral artery showing normal interval change with no evidence of new hemorrhage or expansion of the area of infarction. An electrocardiogram (ECG) is performed, which is shown in the exhibit (see image below). Which of the following is the most appropriate intervention to best prevent future cerebrovascular accidents (CVAs) in this patient?", "answer": "Begin warfarin and heparin", "options": {"A": "Begin aspirin therapy", "B": "Begin clopidogrel", "C": "Carotid endarterectomy", "D": "Begin warfarin and heparin"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man presents", "episodes of palpitations", "past", "weeks", "episodes", "feels", "heart", "racing", "pounding", "lasting 12 hours", "average", "Initially", "episodes", "happen", "times", "week", "now happen almost every day", "last episode", "constant", "past 2 days", "denies", "seizure", "loss of consciousness", "dizziness", "chest pain", "similar symptoms", "past", "past medical history", "significant", "ischemic stroke", "right anterior cerebral artery", "month", "status post intravenous", "tissue plasminogen activator", "residual neurologic impairment", "long standing gastroesophageal reflux secondary to", "hiatal hernia", "managed", "patient reports", "pack-year smoking history", "alcohol", "recreational drug use", "vital signs include", "temperature", "98", "blood pressure 100 70 mm Hg", "pulse", "min", "respiratory rate", "min", "physical examination", "muscle strength", "lower extremities", "4/5", "left", "5/5", "right", "sensory loss", "left", "improved", "previous exam", "weeks", "loss", "left", "visual", "stable", "previous exam", "Cardiac examination", "significant", "new-onset irregular rate", "rhythm", "rubs", "thrills", "murmurs", "computed tomography", "scan shows evidence", "area", "infarction", "right anterior cerebral artery showing normal interval change", "evidence", "new hemorrhage", "area", "infarction", "electrocardiogram", "performed", "shown", "exhibit", "see image", "following", "most appropriate intervention", "best prevent future cerebrovascular accidents", "patient"]}
{"question": "In 2005, a group of researchers believed that prophylactically removing the ovaries and fallopian tubes (bilateral salpingo-oophorectomy) in BRCA-mutation positive women would reduce the chance that they developed breast cancer. To test this hypothesis, they reviewed a database of women who were known to be BRCA-mutation positive and divided the group into those with breast cancer and those without breast cancer. They used data in the registry and surveys about peoples’ surgical history to compare the proportion of each population that had undergone a bilateral salpingo-oophorectomy. Based on this data, they reported that women undergoing the procedure had a lower chance of developing breast cancer later in life with an odds ratio of 0.46. This is an example of what type of study design?", "answer": "Case-control", "options": {"A": "Meta-analysis", "B": "Cross-sectional", "C": "Case-control", "D": "Genome-wide association study"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["a group", "researchers", "removing", "ovaries", "fallopian tubes", "bilateral salpingo-oophorectomy", "mutation positive women", "chance", "breast cancer", "To test", "hypothesis", "reviewed", "database", "women", "known to", "mutation positive", "divided", "group", "breast cancer", "breast cancer", "used data", "registry", "surveys", "peoples surgical history to compare", "proportion", "population", "bilateral salpingo-oophorectomy", "Based", "data", "reported", "women", "procedure", "lower chance of", "breast cancer later", "life", "odds ratio", "0.46", "example", "type", "study"]}
{"question": "A 64-year-old man with a history of type 2 diabetes mellitus is referred to a urologist. The patient has had pain when urinating and difficulty starting a stream of urine for over 4 months now. He is bothered because he has to urinate about 9 times every day, including several times when he wakes up at night. A digital rectal examination revealed multiple hard nodules in the prostate gland. A CT scan shows a nodule in the right lung that measures 3 cm. An ultrasound scan of his urinary bladder and prostate shows residual urine of > 200 mL and heterogeneous findings of the prostate gland. Biopsy reveals grade 2 prostate adenocarcinoma. Follow-up 9 months later shows his prostate cancer is well controlled with goserelin. If one considers pulmonary nodules that are the same size as this patient’s, which of the following additional findings on CT scans would most likely prompt the removal of such nodules?", "answer": "Extending fine striations", "options": {"A": "‘Popcorn’ pattern", "B": "Subsolid component", "C": "Extending fine striations", "D": "Doubling time of < 1 month"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["64 year old man", "history of type 2 diabetes mellitus", "referred", "urologist", "patient", "pain", "difficulty starting", "stream of urine", "over", "months now", "to", "times", "day", "including several times", "wakes up", "night", "digital rectal examination revealed multiple hard nodules", "prostate", "CT scan shows", "nodule", "right", "measures 3", "ultrasound scan of", "urinary bladder", "prostate shows residual urine", "200 mL", "heterogeneous findings of", "prostate gland", "Biopsy reveals grade prostate adenocarcinoma", "Follow-up 9 months later shows", "prostate cancer", "well controlled", "goserelin", "one considers pulmonary nodules", "same size", "patients", "following additional findings", "CT scans", "most likely prompt", "removal", "nodules"]}
{"question": "A 35-year-old man presents with a 7 month history of insomnia. The patient admitted to having trouble sleeping from a young age but became more aware of how much this is affecting his health after attending a sleep conference earlier this year. He is worried that his health has suffered because of this, and he is also concerned that he will not be able to pay his bills if he were to get sick. He has no past medical or psychiatric condition and is not known to use any recreational drugs. The patient arrived for his appointment an hour early because he was afraid he might miss it. The patient is afebrile and his vital signs are within normal limits. Physical examination reveals an irritable middle age man who is tense and somewhat inattentive during the interview. Which of the following is the most likely diagnosis in this patient?\n ", "answer": "Generalized anxiety disorder", "options": {"A": "Generalized anxiety disorder", "B": "Adjustment disorder", "C": "Social anxiety ", "D": "Normal worry"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old man presents", "month history", "insomnia", "patient admitted", "trouble sleeping", "young age", "more aware", "affecting", "health", "attending", "sleep conference earlier", "year", "worried", "health", "suffered", "concerned", "not", "able to pay", "bills", "to", "sick", "past medical", "psychiatric condition", "not known to use", "recreational drugs", "patient arrived", "appointment", "hour early", "afraid", "miss", "patient", "afebrile", "vital signs", "normal limits", "Physical examination reveals", "irritable middle age man", "tense", "somewhat inattentive", "interview", "following", "most likely diagnosis", "patient"]}
{"question": "A 3-year-old girl is brought to the cardiologist because of sweating and respiratory distress while eating. She is at the 30th percentile for height and 15th percentile for weight. Echocardiography shows a defect in the membranous portion of the interventricular septum and a moderately decreased left ventricular ejection fraction. Physical examination is most likely to show which of the following findings?", "answer": "Systolic murmur that increases with hand clenching", "options": {"A": "Systolic murmur that increases with hand clenching", "B": "Systolic murmur that increases with forced exhalation against a closed glottis", "C": "Diastolic murmur preceded by opening snap", "D": "Continuous murmur that is loudest at the second heart sound"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "cardiologist", "sweating", "respiratory distress", "eating", "percentile", "height", "percentile", "weight", "Echocardiography shows", "defect", "membranous portion of", "interventricular septum", "moderately decreased left ventricular ejection fraction", "Physical examination", "most likely to show", "following findings"]}
{"question": "A 58-year-old man comes to the emergency department because of increasing shortness of breath and a nonproductive cough for the last week. Three weeks ago, he had a fever and a cough for 6 days after he returned from a trip to Southeast Asia. He has had a 4-kg (9-lb) weight loss over the past 3 months. He has bronchial asthma and hypertension. He has smoked one pack of cigarettes daily for 41 years. Current medications include an albuterol inhaler and enalapril. His temperature is 37.6°C (99.7°F), pulse is 88/min, respirations are 20/min, and blood pressure is 136/89 mm Hg. There is dullness to percussion, decreased breath sounds, and decreased tactile fremitus over the left lung base. Cardiac examination shows no abnormalities. Chest x-ray of this patient is most likely to show which of the following?", "answer": "Blunting of costophrenic angle", "options": {"A": "Elevation of diaphragm", "B": "Ground glass appearance", "C": "Widened intercostal spaces", "D": "Blunting of costophrenic angle"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["58 year old man", "emergency department", "of increasing shortness", "breath", "nonproductive cough", "week", "Three weeks", "fever", "cough", "6 days", "returned", "trip", "Southeast Asia", "4 kg", "weight loss over", "past 3 months", "bronchial asthma", "hypertension", "smoked one pack", "cigarettes daily", "years", "Current medications include", "albuterol inhaler", "enalapril", "temperature", "99", "pulse", "88 min", "respirations", "20 min", "blood pressure", "mm Hg", "dullness", "percussion", "decreased breath sounds", "decreased tactile fremitus", "left lung base", "Cardiac examination shows", "abnormalities", "Chest x-ray of", "patient", "most likely to show", "following"]}
{"question": "A 58-year-old man is brought to the emergency department because of sudden-onset right-sided body numbness for 1 hour. He reports that he has a 15-year history of hypertension treated with hydrochlorothiazide. He is alert and oriented to time, place, and person. Neurological examination shows decreased sensation to light pinprick and temperature on the right side of the face and body. Motor strength is 5/5 and deep tendon reflexes are 2+ bilaterally. Perfusion of which of the following structures of the brain is most likely impaired in this patient?", "answer": "Ventral thalamus", "options": {"A": "Posterior limb of the internal capsule", "B": "Lateral medulla", "C": "Basal pons", "D": "Ventral thalamus"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old man", "brought", "emergency department", "of sudden-onset right-sided body numbness", "hour", "reports", "year history of hypertension treated with hydrochlorothiazide", "alert", "oriented to time", "place", "person", "Neurological examination shows decreased sensation", "light pinprick", "temperature", "right side of", "face", "body", "Motor strength", "5/5", "deep tendon reflexes", "2", "Perfusion of", "following structures", "brain", "most likely impaired", "patient"]}
{"question": "A 9-year-old boy is brought in by his mother because of bruising on his torso and limbs. The patient’s mother denies any other symptoms and says he is otherwise healthy. Physical examination shows multiple petechiae and bruising on the torso and extremities bilaterally. The remainder of the physical exam is unremarkable. A complete blood count is normal. His coagulation profile reveals:\nProthrombin time (PT) 12 sec\nActivated partial thromboplastin time (aPTT) 60 sec\nWhich of the following is the most likely diagnosis in this patient?", "answer": "Von Willebrand disease", "options": {"A": "Acute lymphoblastic leukemia", "B": "Immune thrombocytopenic purpura", "C": "Von Willebrand disease", "D": "Hemophilia A"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "mother", "bruising", "torso", "limbs", "patients mother denies", "symptoms", "healthy", "Physical examination shows multiple petechiae", "bruising", "torso", "extremities", "physical exam", "unremarkable", "complete blood count", "normal", "coagulation profile reveals", "Prothrombin time", "sec Activated partial thromboplastin time", "60", "following", "most likely diagnosis", "patient"]}
{"question": "A 31-year-old man comes to the physician because of a 4-week history of a painless lump near the left wrist and tingling pain over his left hand. Physical examination shows a transilluminating, rubbery, fixed, non-tender mass over the lateral volar aspect of the left wrist. There is decreased sensation to pinprick on the thumb, index finger, middle finger, and radial half of the ring finger of the left hand. The tingling pain is aggravated by tapping over the swelling. Which of the following adjacent structures is at risk of entrapment if this mass persists?", "answer": "Flexor pollicis longus tendon", "options": {"A": "Ulnar artery", "B": "Flexor pollicis longus tendon", "C": "Flexor carpi radialis tendon", "D": "Ulnar nerve"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["31 year old man", "physician", "4 week history", "painless lump", "left wrist", "tingling pain", "left", "Physical examination shows", "rubbery", "fixed", "non-tender mass", "lateral volar aspect of", "left wrist", "decreased sensation", "pinprick", "thumb", "index finger", "middle finger", "radial half of", "ring finger", "left hand", "tingling pain", "aggravated", "swelling", "following adjacent structures", "at risk", "entrapment", "mass"]}
{"question": "A 52-year-old man comes to the physician for the evaluation of a painless right-sided scrotal swelling. The swelling started several weeks ago but is not always present. Physical examination shows an 8-cm, soft, cystic nontender right-sided scrotal mass that transilluminates. The mass does not increase in size on coughing and it is possible to palpate normal tissue above the mass. There are no bowel sounds in the mass, and it does not reduce when the patient is in a supine position. Examination of the testis shows no abnormalities. Which of the following is the most likely cause of the mass?", "answer": "Imbalance of fluid secretion and resorption by tunica vaginalis", "options": {"A": "Imbalance of fluid secretion and resorption by tunica vaginalis", "B": "Failure of processus vaginalis to obliterate", "C": "Extension of abdominal contents through the inguinal canal", "D": "Dilation and tortuosity of veins in the pampiniform plexus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "evaluation of", "painless right-sided scrotal swelling", "swelling started", "weeks", "not always present", "Physical examination shows", "soft", "cystic nontender right-sided scrotal", "mass", "not increase in size", "coughing", "possible to palpate normal tissue", "mass", "bowel", "mass", "not", "patient", "supine position", "Examination of", "testis shows", "abnormalities", "following", "most likely cause", "mass"]}
{"question": "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?", "answer": "Emergent fasciotomy", "options": {"A": "Emergent fasciotomy", "B": "Venous doppler", "C": "Arteriogram", "D": "External fixation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["40 year old patient", "brought", "emergency department", "suffering", "motor vehicle crash", "pinned", "motorcycle", "about 30 minutes", "called", "evaluating", "institution's trauma guidelines", "discover pain", "palpation", "right", "much larger", "left", "patient admits", "decreased sensation", "right lower extremity", "move", "leg", "palpable", "posterior tibial pulses", "extremity", "colder", "paler", "comparison to", "left side", "Measured compartment pressure", "distal right leg", "35 mm Hg", "next best step", "patient's care"]}
{"question": "An 18-month-old boy is brought to the physician by his mother because of a 2-day history of fever and a pruritic rash that started on his trunk and then progressed to his face and extremities. He has not received any childhood vaccinations because his parents believe that they are dangerous. His temperature is 38.0°C (100.4°F). A photograph of the rash is shown. Which of the following is the most likely diagnosis?", "answer": "Varicella", "options": {"A": "Nonbullous impetigo", "B": "Varicella", "C": "Rubella", "D": "Erythema infectiosum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "physician", "mother", "2-day history", "fever", "pruritic rash", "started", "trunk", "then progressed", "face", "extremities", "not received", "childhood vaccinations", "parents", "dangerous", "temperature", "100 4F", "photograph", "rash", "shown", "following", "most likely diagnosis"]}
{"question": "A 43-year-old male is brought to the emergency department after his son found him vomiting bright red blood. He is visibly intoxicated, and hospital records indicate a long history of alcohol substance abuse treated with antabuse (disulfiram). Vital signs include T 98.4, HR 89, BP 154/92, and RR 20. EGD is notable for mild esophagitis, and a longitudinal esophageal tear at the gastroesophageal junction, with no active bleeding. What is the next best course of action?", "answer": "Conservative management with IV fluid hydration and observation", "options": {"A": "Cyanoacrylate injection and ligation with banding, IV fluid hydration, and NPO", "B": "Conservative management with IV fluid hydration and observation", "C": "Esophageal manometry and impedance studies", "D": "Calcium channel blockage and Botox injection of the lower esophageal sphincter"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male", "brought", "emergency department", "son found", "vomiting bright red blood", "hospital records", "long history of substance treated with antabuse", "disulfiram", "Vital signs include T 4", "BP", "RR 20", "EGD", "notable", "mild esophagitis", "longitudinal esophageal tear", "gastroesophageal junction", "active bleeding", "next best course", "action"]}
{"question": "A medical student is preparing a patient for an appendectomy. He is asked by the surgeon to disinfect the patient’s skin with a chlorhexidine-isopropyl alcohol solution before the procedure. Recent studies have shown that this solution substantially reduces the risk of surgical site infections compared with a povidone-iodine preparation without alcohol in clean-contaminated surgery. Which of the following mechanisms best describes the mechanism of action of chlorhexidine?", "answer": "Its activity depends on pH and is greatly reduced in the presence of organic matter", "options": {"A": "Bactericidal at low concentrations", "B": "Cell wall damage by free radical release", "C": "Attack of free-sulfur amino acids, nucleotides, and fatty acids within the bacteria", "D": "Its activity depends on pH and is greatly reduced in the presence of organic matter"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["medical student", "preparing", "patient", "appendectomy", "surgeon to", "patients skin", "chlorhexidine-isopropyl alcohol solution", "procedure", "Recent studies", "shown", "solution", "risk of surgical site infections compared", "povidone-iodine preparation", "alcohol", "clean contaminated surgery", "following mechanisms best", "mechanism of action", "chlorhexidine"]}
{"question": "A 19-year-old man with a past medical history significant only for facial acne presents with increased inguinal pruritis. Relevant social history includes participation in school wrestling. He has no significant family history. Other than the pruritic rash, a review of systems is negative. On physical examination, there is an erythematous, well-demarcated patch on his left thigh, over his pubic region, and throughout the perineum. The scrotum is spared. Which of the following is the most likely diagnosis?", "answer": "Tinea cruris", "options": {"A": "Tinea corporis", "B": "Tinea cruris", "C": "Candidal balanitis", "D": "Tinea unguium"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "past medical history significant only", "facial acne presents", "increased inguinal pruritis", "Relevant social history includes participation", "school wrestling", "significant family history", "pruritic rash", "review of systems", "negative", "physical examination", "erythematous", "well", "patch", "left thigh", "pubic region", "perineum", "scrotum", "following", "most likely diagnosis"]}
{"question": "A 6-week-old girl is brought to the pediatrician for a post-natal visit. She was born at 38 weeks gestation to a 25-year-old woman via an uncomplicated spontaneous vaginal delivery. The mother reports that prenatal screening revealed no developmental abnormalities and that the baby has been gaining weight, feeding, stooling, and urinating appropriately. Physical exam of the infant is unremarkable. The mother has a history of polycystic ovarian syndrome and is curious about the development of her daughter's ovaries. Which of the following is true regarding the baby’s reproductive system at this time?", "answer": "The baby’s oocytes are arrested in prophase", "options": {"A": "The baby has not yet developed oocytes", "B": "The baby’s oocytes are arrested in prophase", "C": "The baby’s oocytes are arrested in interphase", "D": "The baby’s oocytes are fully matured"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["week old girl", "brought", "pediatrician", "post natal visit", "born", "weeks gestation", "year old woman", "uncomplicated spontaneous vaginal delivery", "mother reports", "prenatal screening revealed", "developmental abnormalities", "baby", "gaining weight", "feeding", "stooling", "Physical exam", "infant", "unremarkable", "mother", "history", "polycystic ovarian syndrome", "curious", "development", "daughter's ovaries", "following", "true", "reproductive system", "time"]}
{"question": "A 7-year-old boy is brought to the physician because of a 3-week history of burning sensation in his mouth. One year ago, a peripheral blood smear performed during workup of fatigue revealed erythrocytes without central pallor. His father had gallstones, for which he underwent a cholecystectomy at the age of 26 years. Examination shows pallor of the mucosal membranes, mild scleral icterus, a swollen, red tongue, and several mouth ulcers. There is darkening of the skin over the dorsal surfaces of the fingers, toes, and creases of the palms and soles. His spleen is enlarged and palpable 3 cm below the left costal margin. Laboratory studies show a hemoglobin concentration of 9.1 gm/dL, mean corpuscular volume of 104 μm3, and a reticulocyte count of 9%. Which of the following would most likely have prevented this patient's oropharyngeal symptoms?", "answer": "Folic acid supplementation", "options": {"A": "Red blood cell transfusions", "B": "Gluten-free diet", "C": "Vitamin B12 injections", "D": "Folic acid supplementation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "3 week history", "burning sensation", "mouth", "One year ago", "peripheral blood smear performed", "workup", "fatigue revealed erythrocytes", "central pallor", "father", "gallstones", "cholecystectomy", "age", "years", "Examination shows pallor", "mucosal membranes", "mild scleral icterus", "swollen", "red", "several mouth", "darkening", "skin", "dorsal surfaces of", "fingers", "toes", "creases", "palms", "soles", "spleen", "enlarged", "palpable 3 cm", "left costal margin", "Laboratory studies show a hemoglobin concentration", "1 gm dL", "mean corpuscular volume", "m3", "reticulocyte count", "following", "most likely", "prevented", "patient's oropharyngeal symptoms"]}
{"question": "An experimental new drug in the treatment of diabetes mellitus type 2 was found to increase the levels of incretins by preventing their degradation at the endothelium. This further increased glucose-dependent insulin production. Which of the following drugs has a mechanism of action most similar to this new experimental drug?", "answer": "Sitagliptin", "options": {"A": "Sitagliptin", "B": "Glimepiride", "C": "Canagliflozin", "D": "Pioglitazone"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["experimental new drug", "treatment", "diabetes mellitus type 2", "found to increase", "levels", "incretins", "preventing", "degradation", "endothelium", "further increased dependent insulin production", "following drugs", "mechanism of action most similar", "new experimental drug"]}
{"question": "A 60-year-old man with severe persistent asthma since the age of 14 presents with an acute exacerbation of shortness of breath, wheezing, and coughing over the last several days. His asthmatic symptoms are usually well controlled with regular high-dose inhaled triamcinolone, but over the last week or so he has developed a nocturnal cough and mild wheezing despite good compliance with controller medications. A review of several spirometry reports suggest of bronchial asthma with a partial irreversible airway obstruction. Which of the following is most likely to be associated with the recent loss of asthma control in this patient?", "answer": "Airway remodeling", "options": {"A": "Airway epithelial shedding", "B": "Airway smooth muscle atrophy", "C": "Airway remodeling", "D": "Airway hyperresponsiveness"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "severe persistent asthma", "age", "presents", "acute exacerbation of shortness", "breath", "wheezing", "coughing", "days", "asthmatic symptoms", "usually well controlled", "regular high-dose inhaled triamcinolone", "last week", "so", "nocturnal cough", "mild wheezing", "good compliance", "controller medications", "review", "spirometry reports suggest", "bronchial asthma", "partial", "airway", "following", "most likely to", "associated with", "recent loss", "asthma control", "patient"]}
{"question": "A 75-year-old man is admitted to the hospital because of a 3-day history of a productive cough and shortness of breath. His temperature is 38°C (100.4°F) and respirations are 32/min. Crackles are heard over the right upper and the entire left lung fields. Sputum culture confirms infection with Streptococcus pneumoniae. Despite appropriate therapy, the patient dies. A photomicrograph of a section of the lung obtained during the autopsy is shown. Which of the following mediators is most likely responsible for the presence of the cell-type indicated by the arrow?", "answer": "Platelet activating factor", "options": {"A": "Platelet activating factor", "B": "Interferon-gamma", "C": "Interleukin-10", "D": "Leukotriene D4"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["75 year old man", "admitted", "hospital", "3-day history", "productive cough", "shortness of breath", "temperature", "100 4F", "respirations", "min", "Crackles", "heard", "right upper", "entire left lung fields", "Sputum culture confirms infection", "Streptococcus pneumoniae", "appropriate therapy", "patient", "photomicrograph", "section", "lung obtained", "autopsy", "shown", "following mediators", "most likely responsible", "presence of", "cell-type indicated", "arrow"]}
{"question": "A 2-month-old infant is brought to the emergency department by her mother due to a fall. Tearfully, the patient’s mother describes witnessing her child fall from the changing table. The patient was born prematurely at 36 weeks estimated gestational age via vacuum-assisted vaginal delivery. The patient is afebrile. Her vital signs include: blood pressure of 94/60 mm Hg, pulse 200/min, and respiratory rate 70/min. Physical examination reveals a subconjunctival hemorrhage in the left eye and multiple bruises on the chest and back. Which of the following is the best initial step in management of this patient’s condition?", "answer": "CT scan of the head", "options": {"A": "CT scan of the head", "B": "Involvement of social services", "C": "Family counseling", "D": "Rule out medical conditions"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["2 month old infant", "brought", "emergency department", "mother due to", "fall", "patients mother", "witnessing", "child fall from", "changing table", "patient", "born", "36 weeks estimated gestational age", "vacuum assisted vaginal delivery", "patient", "afebrile", "vital signs include", "blood pressure", "60 mm Hg", "pulse 200 min", "respiratory rate 70 min", "Physical examination reveals", "subconjunctival hemorrhage", "left eye", "multiple bruises", "chest", "back", "following", "best initial step", "management", "patients condition"]}
{"question": "A researcher is interested in identifying the most effective treatment for uncomplicated urinary tract infections (UTI) in women between the ages of 18 and 50. Of 200 consecutive women who present to the emergency room for such a UTI, 50 are randomized to each of the following: nitrofurantoin 100 mg every 12 hours for 5 days, nitrofurantoin 100 mg every 12 hours for 7 days, cefpodoxime 100 mg every 12 hours for 5 days, and cefpodoxime 100 mg every 12 hours for 7 days. The measured outcomes include progression to pyelonephritis, positive urine culture on day 7 after initiation of treatment, and likelihood of re-presenting to the emergency room for another UTI within 90 days. Which of the following best describes this type of study?", "answer": "Factorial design study", "options": {"A": "Parallel study", "B": "Factorial design study", "C": "Between patient study", "D": "Cluster randomized trial"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["researcher", "interested", "most effective treatment", "uncomplicated urinary tract infections", "women", "ages", "50", "200 consecutive women", "present", "emergency room", "UTI", "50", "randomized", "following", "nitrofurantoin 100 mg", "hours", "days", "nitrofurantoin 100 mg", "hours", "days", "cefpodoxime 100 mg", "hours", "days", "cefpodoxime 100 mg", "hours", "days", "measured outcomes include progression", "pyelonephritis", "positive urine culture", "day 7", "initiation", "treatment", "likelihood", "re presenting", "emergency room", "UTI", "90 days", "following best", "type", "study"]}
{"question": "A 31-year-old man comes to the emergency department because of acute onset neck pain and enlargement. Specifically, he reports that he has been experiencing pain and swelling of the anterior portion of his neck near the midline. Otherwise, he says that he has been getting tired easily and feels cold often. Physical exam reveals a painful diffusely enlarged thyroid gland with many small nodules. A biopsy is obtained showing diffuse cellular hyperplasia with areas of focal colloid hyperplasia. Given these findings, the patient is started on appropriate therapy, and the neck mass becomes smaller over time. Which of the following is most likely associated with the cause of this patient's symptoms?", "answer": "Iodine deficiency", "options": {"A": "HLA-B8 risk factor", "B": "Iodine deficiency", "C": "Presence of embryological remnant", "D": "Proliferation of fibroinflammatory cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["31 year old man", "emergency department", "acute onset neck pain", "enlargement", "reports", "experiencing pain", "swelling of the anterior portion", "neck", "midline", "getting tired easily", "feels cold often", "Physical exam reveals", "painful", "enlarged", "small nodules", "biopsy", "obtained showing diffuse cellular hyperplasia", "areas", "focal colloid", "Given", "findings", "patient", "started", "appropriate therapy", "neck mass", "smaller", "time", "following", "most likely associated", "cause", "patient's symptoms"]}
{"question": "A 25-year-old man presents to the office because of extreme fatigue for the past 2 days. He is also worried about his skin looking yellow. He does not have any other complaints and denies fever and headache. He admits to using illicit intravenous drugs in the past. He does not have any immunization records because he moved from Africa to the US at the age of 18. His vital signs are as follows: heart rate 72/min, respiratory rate 14/min, temperature 37.9°C (100.2°F), and blood pressure 100/74 mm Hg. Physical examination is not significant except for mild diffuse abdominal tenderness. His blood is drawn for routine tests and shows an alanine aminotransferase level (ALT) of 2,000 IU/L. A hepatitis viral panel is ordered which shows:\nAnti-HAV IgM negative\nHBsAg positive\nAnti-HBs negative\nIgM anti-HBc positive\nAnti-HCV negative\nAnti-HDV negative\nWhat is the most likely diagnosis?", "answer": "Acute hepatitis B", "options": {"A": "Past hepatitis B infection", "B": "Acute hepatitis A", "C": "Acute hepatitis D superinfection", "D": "Acute hepatitis B"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "office", "of extreme fatigue", "past 2 days", "worried", "skin looking yellow", "not", "complaints", "denies fever", "headache", "admits to using illicit intravenous drugs", "past", "not", "immunization records", "moved from Africa", "age", "vital signs", "follows", "heart rate 72 min", "respiratory rate", "min", "temperature", "100", "blood pressure 100 74 mm Hg", "Physical examination", "not significant", "mild diffuse abdominal tenderness", "blood", "drawn", "routine tests", "shows", "alanine aminotransferase level", "ALT", "2", "IU/L", "hepatitis viral panel", "ordered", "shows", "Anti-HAV negative HBsAg positive", "HBs", "HBc", "HCV", "HDV", "most likely diagnosis"]}
{"question": "A 29-year-old female presents to her primary care provider with an aching pain in her left leg that has progressively gotten worse over several days. She recently had an unfortunate sporting incident resulting in large bruises along both legs and lower thighs. An X-ray after the event was negative for fracture. Past medical history is positive for systemic lupus erythematosus. She also has a history of one spontaneous abortion at 12 weeks gestation. Today, her heart rate is 90/min, respiratory rate is 17/min, blood pressure is 119/80 mm Hg, and temperature is 37.0°C (98.6°F). On physical examination, her left leg appears pink and slightly swollen. Homan’s sign is positive. A Doppler ultrasound reveals a thrombus in the left popliteal vein. Her lab results are as follows:\nPlatelets 250,000/mm3\nProthrombin Time 14 sec\nPartial Thromboplastin Time 90 sec\nMixing study (PTT) 89 sec\nWhat is the most likely cause of the patient’s condition?", "answer": "Antibodies directed against phospholipids", "options": {"A": "Antibodies directed against platelet glycoprotein IIb/IIIa", "B": "Antibodies directed against phospholipids", "C": "Antibodies directed against endothelial cells", "D": "Vitamin K deficiency"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["29 year old female presents", "primary care provider", "aching pain in", "left leg", "gotten worse", "days", "recently", "sporting incident resulting in large bruises", "legs", "lower thighs", "X-ray", "event", "negative", "fracture", "Past medical history", "positive", "systemic lupus erythematosus", "history of one spontaneous abortion", "weeks gestation", "Today", "heart rate", "90 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "temperature", "98", "physical examination", "left leg appears pink", "slightly swollen", "Homans sign", "positive", "Doppler ultrasound reveals", "thrombus", "left popliteal vein", "lab results", "follows", "Platelets", "mm3 Prothrombin", "sec Partial Thromboplastin Time 90", "Mixing study", "PTT", "sec", "most likely cause", "patients condition"]}
{"question": "A 22-year-old woman with a history of asthma visits her physician for worsening shortness of breath. She states that she feels as though her “lungs are falling apart,” noting that her lung function has been steadily deteriorating. She further states that she has visited a number of other physicians who prescribed several different types of inhalers, but she feels that they have not helped her control her asthma exacerbations. She has experienced 4 episodes of pneumonia in the last 3 years and often suffers from “random” bouts of excessive coughing and wheezing. When asked if her coughing episodes produce sputum, she states, “Yes, the stuff is greenish with specks of red in it.” She also states that her coughing and wheezing episodes are associated with fever, malaise, and occasional expectoration of brown mucous plugs. The vital signs include: blood pressure 122/70 mm Hg, pulse 66/min, respiratory rate 26/min, and temperature 37.0°C (98.6°F). On physical exam, the patient appears frail-looking and in moderate respiratory distress. Auscultation reveals inspiratory crackles in the right lung base and coarse breath sounds in the bilateral upper lung lobes. Chest radiograph, as shown below, reveals atelectasis in the right lung base. There are also branched radiodensities that the radiologist notes as being “glove-finger shadows” (noted by the arrow in the image). Serum immunoglobulin E (IgE) levels are elevated. Which of the following is the most appropriate therapy in this patient?", "answer": "Prednisone", "options": {"A": "Isoniazid", "B": "Fluconazole", "C": "Caspofungin", "D": "Prednisone"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "history of asthma visits", "physician", "worsening shortness of breath", "states", "feels", "lungs", "falling", "noting", "lung function", "deteriorating", "further states", "visited", "number", "physicians", "prescribed several different types", "inhalers", "feels", "not helped", "control", "asthma exacerbations", "experienced 4 episodes of pneumonia", "last", "years", "often suffers", "random bouts of excessive coughing", "wheezing", "coughing episodes", "sputum", "states", "Yes", "red", "states", "coughing", "wheezing episodes", "associated with fever", "malaise", "occasional expectoration", "brown mucous plugs", "vital signs include", "blood pressure", "70 mm Hg", "pulse 66 min", "respiratory rate", "min", "temperature", "98", "physical exam", "patient appears frail looking", "moderate respiratory distress", "Auscultation reveals inspiratory crackles", "right lung base", "coarse breath sounds", "bilateral upper lung lobes", "Chest radiograph", "shown", "reveals atelectasis", "right lung base", "branched radiodensities", "radiologist notes", "glove finger shadows", "noted", "arrow", "image", "Serum immunoglobulin E", "levels", "elevated", "following", "most appropriate therapy", "patient"]}
{"question": "A 30-year-old man is brought to the emergency department with complaints of fever (41.5℃ (106.7℉)) and diarrhea for the past 12 hours. There is no history of headaches, vomiting, or loss of consciousness. The past medical history is unobtainable due to a language barrier (the patient recently immigrated from abroad), but his wife says her husband had a motor vehicle accident when he was a teenager that required surgery. He is transferred to the ICU after a few hours in the ED because of dyspnea, cyanosis, and near-collapse. There are no signs of a meningeal infection. The Blood pressure was 70/30 mm Hg at the time of transfer. A chest X-ray at the time of admission showed interstitial infiltrates without homogeneous opacities. The initial laboratory results reveal metabolic acidosis, leukopenia with a count of 2,000/mm³, thrombocytopenia (15,000/mm³), and a coagulation profile suggestive of disseminated coagulation. A peripheral smear was performed and is shown below. Despite ventilatory support, administration of intravenous fluids, antibiotics, and vasopressor agents, the patient died the next day. A gram stain from an autopsy specimen of the lungs revealed gram-positive, lancet-shaped diplococci occurring singly or in chains. Which of the following organisms is most likely?", "answer": "Streptococcus pneumoniae", "options": {"A": "Staphylococcus aureus", "B": "Streptococcus pyogene", "C": "Streptococcus pneumoniae", "D": "Non-typeable H. influenzae"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["30 year old man", "brought", "emergency department", "complaints", "fever", "diarrhea", "past 12 hours", "history of headaches", "vomiting", "loss of consciousness", "past medical history", "due to", "language barrier", "patient recently", "wife", "husband", "motor vehicle accident", "teenager", "required surgery", "transferred to", "ICU", "few hours", "ED", "dyspnea", "cyanosis", "near collapse", "signs", "meningeal infection", "Blood pressure", "70 30 mm Hg", "time", "transfer", "chest X-ray", "time of admission showed interstitial infiltrates", "homogeneous opacities", "initial laboratory results reveal metabolic acidosis", "leukopenia", "count", "mm", "thrombocytopenia", "mm", "coagulation profile suggestive of disseminated coagulation", "peripheral smear", "performed", "shown", "support", "administration of intravenous fluids", "antibiotics", "vasopressor agents", "patient died", "next day", "gram stain from", "autopsy specimen", "lungs revealed gram-positive", "lancet shaped diplococci occurring", "chains", "following organisms", "most likely"]}
{"question": "A 12-year-old girl is brought to the emergency department 3 hours after the sudden onset of colicky abdominal pain and vomiting. The patient also manifests symptoms of redness and swelling of the face and lips without pruritus. Her symptoms began following a tooth extraction earlier in the morning. She had a similar episode of facial swelling after a bicycle accident 1 year ago, which resolved within 48 hours without treatment. Vital signs are within normal limits. Examination shows a nontender facial edema, erythema of the oral mucosa, and an enlarged tongue. The abdomen is soft, and there is tenderness to palpation over the lower quadrants. An abdominal ultrasound shows segmental thickening of the intestinal wall. Which of the following is the most likely cause of this patient's condition?", "answer": "Complement inhibitor deficiency", "options": {"A": "Autoantibody-mediated tissue damage", "B": "Complement inhibitor deficiency", "C": "Drug-induced bradykinin excess", "D": "Mast-cell activation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "emergency department", "hours", "sudden onset", "colicky abdominal pain", "vomiting", "patient", "manifests symptoms", "redness", "swelling of", "face", "lips", "pruritus", "symptoms began following", "tooth extraction earlier", "morning", "similar episode of facial swelling", "bicycle accident", "year", "resolved", "48 hours", "treatment", "Vital signs", "normal limits", "Examination shows", "nontender facial edema", "erythema of", "oral mucosa", "enlarged tongue", "abdomen", "soft", "tenderness", "palpation", "lower quadrants", "abdominal ultrasound shows segmental thickening", "intestinal", "following", "most likely cause", "patient's condition"]}
{"question": "A healthy 21-year-old man undergoes physical fitness testing prior to long-term submarine deployment. To evaluate his pulmonary function, lung and thoracic compliance are measured at different system pressures. A graph of the relationship between his lung volume and transpulmonary pressure is shown. The dotted line in this graph corresponds to which of the following lung volumes?", "answer": "Functional residual capacity", "options": {"A": "Inspiratory capacity", "B": "Tidal volume", "C": "Functional residual capacity", "D": "Total lung capacity"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy 21-year-old man", "physical fitness testing prior to long-term submarine deployment", "To evaluate", "pulmonary function", "lung", "thoracic compliance", "measured", "different system pressures", "graph", "relationship", "lung volume", "transpulmonary pressure", "shown", "line", "graph", "following lung volumes"]}
{"question": "A 3-day-old boy is brought to the emergency department because of a 4-hour history of somnolence, poor feeding, and one episode of vomiting. He is exclusively breastfed. His serum glucose concentration is 88 mg/dL and his serum ammonia concentration is 850 μmol/L (N<90). Urinalysis shows an increased orotic acid to creatinine ratio. Urinary ketones are absent. This patient is most likely deficient in an enzyme that catalyzes which of the following reactions?", "answer": "Ornithine and carbamoyl phosphate to citrulline", "options": {"A": "Ornithine and carbamoyl phosphate to citrulline", "B": "Orotic acid to uridine monophosphate", "C": "Pyruvate to acetyl-coenzyme A", "D": "Glutamate and acetyl-coenzyme A to N-acetylglutamate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 day old boy", "brought", "emergency department", "4-hour history", "somnolence", "poor feeding", "one episode of vomiting", "breastfed", "serum", "88 mg/dL", "serum ammonia concentration", "850 mol/L", "N 90", "Urinalysis shows", "increased orotic acid", "creatinine ratio", "Urinary ketones", "absent", "patient", "most likely deficient", "enzyme", "following reactions"]}
{"question": "A 31-year-old woman comes to the physician because of dragging pelvic pain and a 3 kg (6 lb 9 oz) weight loss over the past 6 months. Menses occur at irregular 30- to 45-day intervals; her last menstrual period was 5 weeks ago. Her temperature is 38°C (100.4°F), heart rate is 102/min, and blood pressure is 128/84 mm Hg. Physical examination shows hyperreflexia. Urine pregnancy test is negative. Ultrasonography shows a 6-cm hypoechoic adnexal mass. This adnexal mass is most likely derived from which of the following cell types?", "answer": "Germ cells", "options": {"A": "Germ cells", "B": "Chorionic epithelial cells", "C": "Endometrial cells", "D": "Stromal cells"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old woman", "physician", "dragging pelvic pain", "3 kg", "6", "9 oz", "weight loss", "past 6 months", "Menses occur", "irregular 30", "day intervals", "last menstrual period", "5 weeks", "temperature", "100 4F", "heart rate", "min", "blood pressure", "84 mm Hg", "Physical examination shows hyperreflexia", "Urine pregnancy test", "negative", "Ultrasonography shows", "adnexal mass", "adnexal mass", "most likely derived", "of", "following cell types"]}
{"question": "A 55-year-old man comes to the emergency department with the complaint of pain in his right toe for the past hour. The pain is so severe that it woke him up. The patient has smoked a pack of cigarettes daily for the last 40 years and binge drinks alcohol after work and on the weekends. He underwent an appendectomy when he was 14 years old. He is a long-distance truck driver. Neither of his parents had any significant medical history. His temperature is 37.7°C (100°F), blood pressure is 135/75 mm Hg, pulse is 102/min, respiratory rate is 20/min, and BMI is 25 kg/m2. On examination, his right first metatarsophalangeal joint is very tender, swollen, warm, and red in color. Range of motion cannot be assessed due to extreme tenderness.\nLaboratory test\nComplete blood count:\nHemoglobin 11.5 g/dL\nLeukocytes 16,000/mm3\nPlatelets 150,000/mm3\nESR 50 mm/hr\nSynovial fluid is aspirated from the joint. The findings are:\nAppearance Cloudy, dense yellow\nWBC 30,000 cells/µL\nCulture Negative\nNeedle-shaped birefringent crystals are observed in the joint aspirate. Which of the following is the most likely underlying cause of the patient’s condition?", "answer": "Organic acids competing with urate for tubular secretion", "options": {"A": "Organic acids competing with urate for tubular secretion", "B": "Increased renal reabsorption of urate", "C": "Deficiency of HGPRT", "D": "High-purine diet"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["55 year old man", "emergency department", "complaint", "pain", "right toe", "past hour", "pain", "so severe", "woke", "patient", "smoked", "pack", "cigarettes daily", "last 40 years", "binge drinks alcohol", "work", "weekends", "appendectomy", "years old", "long distance truck driver", "parents", "significant medical history", "temperature", "blood pressure", "75 mm Hg", "pulse", "min", "respiratory rate", "20 min", "BMI", "kg/m2", "examination", "right first metatarsophalangeal joint", "very tender", "swollen", "warm", "red", "color", "Range of motion", "assessed due to extreme tenderness", "Laboratory test Complete blood count", "Hemoglobin", "g dL Leukocytes", "mm3 Platelets", "ESR 50 mm hr Synovial fluid", "aspirated", "joint", "findings", "Appearance Cloudy", "dense yellow WBC", "cells/L Culture Negative Needle shaped", "crystals", "observed", "joint aspirate", "following", "most likely underlying cause", "patients condition"]}
{"question": "A 33-year-old man presents to the infectious diseases clinic for follow-up. He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV. His CD4 count is 175, viral load is pending. As part of routine laboratory studies given his new diagnosis, an RPR was found to be positive with a titer of 1:64, and this is confirmed with a positive FTA-ABS. He is unsure when or how he acquired HIV or syphilis. His neurological examination is normal, and he has no symptoms. Which of the following is the most appropriate next step in management:", "answer": "Treat with three weekly injections of penicillin, obtain titers in 6 months", "options": {"A": "Perform lumbar puncture, treat based on presence or absence of CNS disease", "B": "Treat with three weekly injections of penicillin, obtain titers in 3 months", "C": "Treat with three weekly injections of penicillin, obtain titers in 6 months", "D": "Treat with a single injection of penicillin, obtain titers in 6 months"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "infectious diseases clinic", "follow-up", "recently admitted", "hospital", "fever", "shortness of breath", "cough", "found to", "Pneumocystic jirovecii pneumonia", "new", "HIV", "CD4 count", "viral load", "part of routine laboratory studies given", "new diagnosis", "RPR", "found to", "positive", "titer", "64", "confirmed", "positive FTA-ABS", "unsure", "acquired HIV", "syphilis", "neurological examination", "normal", "symptoms", "following", "most appropriate next step", "management"]}
{"question": "A 67-year old man presents to his primary care physician for his yearly checkup. He has not noticed any major changes in his health over the last year but says that unfortunately, he stopped exercising because he has been stressed by work. His past medical history is significant for obesity, hypertension, diabetes, hypercholesterolemia, and hyperlipidemia. He is taking a number of drugs but does not remember what they are. A panel of metabolic and lipid tests are ordered and show worsening of his metabolic parameters. Based on these findings, his physician prescribes a drug that leads to a large decrease in triglycerides with a much smaller increase in high-density lipoproteins and decrease in low-density lipoproteins. The drug that was most likely prescribed in this case is associated with which of the following side effects?", "answer": "Cholelithiasis", "options": {"A": "Cholelithiasis", "B": "Decreased vitamin D absorption", "C": "Hepatotoxicity", "D": "Teratogenicity"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old man presents", "primary care physician", "yearly checkup", "not", "major changes", "health", "last year", "stopped exercising", "stressed", "work", "past medical history", "significant", "obesity", "hypertension", "diabetes", "hypercholesterolemia", "hyperlipidemia", "taking", "number", "drugs", "not remember", "panel", "metabolic", "lipid tests", "ordered", "show worsening", "metabolic parameters", "Based", "findings", "physician", "drug", "leads", "large decrease", "triglycerides", "smaller increase", "high-density lipoproteins", "decrease", "low-density lipoproteins", "drug", "most likely prescribed", "case", "associated with", "following side effects"]}
{"question": "A 29-year-old woman presents to her OB/GYN for a preconception visit. She wishes to become pregnant within the next several months. A thorough history reveals that the patient suffers from phenylketonuria (PKU). She recalls being instructed by prior physicians to follow a diet that avoids certain foods; however, she admits to not being complaint with these recommendations. Laboratory testing reveals a plasma phenylalanine level of 20.2 mg/dL (normal range <2 mg/dL). Which of the following is the most appropriate response to this patient?", "answer": "3 months prior to conception, begin a restricted diet to lower phenylalanine levels to below 6 mg/dL", "options": {"A": "Improved PKU treatment will decrease the risks of spontaneous abortion and intrauterine fetal death", "B": "3 months prior to conception, begin a restricted diet to lower phenylalanine levels to below 6 mg/dL", "C": "Begin a phenylalanine-restricted diet in your first trimester to reduce the risk of fetal morbidity", "D": "Your current phenylalanine levels do not pose a risk to any future pregnancy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old woman presents", "OB/GYN", "preconception visit", "wishes to", "pregnant", "next", "months", "history reveals", "patient suffers", "phenylketonuria", "recalls", "prior physicians to follow", "diet", "certain foods", "admits to not", "complaint", "recommendations", "Laboratory testing reveals", "plasma phenylalanine level", "20.2 mg/dL", "normal range", "2 mg/dL", "following", "most appropriate response", "patient"]}
{"question": "A 47-year-old man presents to his family physician with a sudden onset of severe pain and redness in his eyes that started this morning. He is having difficulty seeing properly and is extremely worried about losing his vision. Further history reveals that he has had progressive lower back pain for over 2 months now. The pain is usually at its worst in the morning, but it remains throughout the day. It gets better with movement, however, so he tends to do some light exercises every day. He also has heel pain and feels significant pressure while walking. Laboratory analysis reveals increased ESR and CRP serum levels. Which of the following would most likely be seen in this patient?", "answer": "Aortic regurgitation", "options": {"A": "Dry mouth", "B": "Malabsorption", "C": "Aortic regurgitation", "D": "Hemochromatosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "family physician", "sudden onset", "severe pain", "redness", "eyes", "started", "morning", "difficulty seeing", "extremely worried", "vision", "Further history reveals", "progressive lower back pain", "over", "months now", "pain", "usually", "worst", "morning", "day", "gets better", "movement", "to", "light exercises", "day", "heel pain", "feels significant pressure", "walking", "Laboratory analysis reveals increased ESR", "CRP serum levels", "following", "most likely", "seen", "patient"]}
{"question": "A 38-year-old woman presents to her physician’s clinic for recurrent episodes of chest pain that wakes her from her sleep. While usually occurring late at night, she has also had similar pains during the day at random times, most recently while sitting at her desk in her office and at other times while doing the dishes at home. The pain lasts 10–15 minutes and resolves spontaneously. She is unable to identify any common preceding event to pain onset. The remainder of her history is unremarkable and she takes no regular medications. She works as an accountant. There is no history of smoking or drug use, however, she does consume 5 alcoholic drinks per week. Examination reveals: pulse 70/min, respirations 16/min, and blood pressure 120/70 mm Hg. A physical examination is unremarkable. Which of the following would be effective in reducing her symptoms?", "answer": "Isosorbide dinitrate", "options": {"A": "Aspirin", "B": "Isosorbide dinitrate", "C": "Heparin", "D": "Propranolol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physicians clinic", "recurrent episodes of chest pain", "wakes", "sleep", "usually occurring late", "night", "similar pains", "day", "random times", "most recently", "sitting", "office", "times", "dishes at home", "pain", "minutes", "resolves", "unable to", "common preceding event", "pain onset", "history", "unremarkable", "takes", "regular medications", "works", "accountant", "history of smoking", "drug use", "5 alcoholic drinks", "week", "Examination reveals", "pulse 70 min", "respirations", "min", "blood pressure", "70 mm Hg", "physical examination", "unremarkable", "following", "effective", "reducing", "symptoms"]}
{"question": "A 16-year-old male presents to his pediatrician with complaints of malaise, fatigue, sore throat, and fever over the last several days. His vital signs are as follows: T 39.1 C, HR 82, BP 122/76, RR 14, and SpO2 99%. Physical examination is significant for splenomegaly, tonsillar exudate, and posterior auricular lymphadenopathy. The tonsils are not notably enlarged. Laboratory work-up shows an elevated lymphocyte count, atypical lymphocytes on a peripheral blood smear, and a positive heterophile antibody screen. Which of the following is the best management of this patient's condition?", "answer": "Bed rest and activity limitation", "options": {"A": "Bed rest and activity limitation", "B": "Ganciclovir", "C": "Amoxicillin", "D": "Prednisone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old male presents", "pediatrician", "complaints", "malaise", "fatigue", "sore throat", "fever", "days", "vital signs", "follows", "T", "BP", "76", "RR", "99", "Physical examination", "significant", "splenomegaly", "tonsillar exudate", "posterior auricular lymphadenopathy", "tonsils", "not", "enlarged", "Laboratory work-up shows", "elevated lymphocyte count", "atypical lymphocytes", "peripheral blood smear", "positive heterophile antibody screen", "following", "best management", "patient's"]}
{"question": "A 75-year-old man comes to the physician because of a 7-day history of nausea and vomiting. Over the past 2 days, he has also been feeling weak and tired. When standing up after sitting for a while, he feels dizzy. He says he has to go to the bathroom more often than usual, and that he is urinating “a normal amount” each time. He has not had diarrhea. He has hypertension, for which he has been taking hydrochlorothiazide for the past 6 months. He drinks 9 glasses of water per day and takes his medication regularly. He is 168 cm (5 ft 6 in) tall and weighs 90 kg (198 lb); BMI is 32 kg/m2. His temperature is 36.5°C (97.7°F), blood pressure is 106/54 mm Hg, and pulse is 92/min. Physical examination shows whitening of the tongue. Skin that is pinched on the back of the hand retracts after 5 seconds. On mental status examination, his speech is slowed; he is oriented to person, place, and time. Laboratory studies show:\nSerum\nNa+ 150 mEq/L\nCl− 97 mEq/L\nK+ 3.6 mEq/L\nHCO3− 30 mEq/L\nOsmolality 354 mOsm/kg\nHemoglobin A1C 10.5%\nUrine\nOsmolality 400 mOsm/kg\nWhich of the following is the most likely explanation for these findings?\"", "answer": "Osmotic diuresis", "options": {"A": "Diuretic overdose", "B": "Osmotic diuresis", "C": "Excess production of aldosterone", "D": "Insufficient production of antidiuretic hormone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["75 year old man", "physician", "7-day history", "nausea", "vomiting", "past 2 days", "feeling weak", "tired", "standing up", "sitting", "feels dizzy", "to go", "bathroom", "often", "usual", "normal amount", "time", "not", "diarrhea", "hypertension", "taking hydrochlorothiazide", "past 6 months", "drinks", "glasses", "water", "day", "takes", "medication", "5 ft 6", "tall", "90 kg", "BMI", "kg/m2", "temperature", "36", "97", "blood pressure", "54 mm Hg", "pulse", "min", "Physical examination shows whitening", "tongue", "Skin", "pinched", "back of", "hand retracts", "seconds", "mental", "speech", "slowed", "oriented to person", "place", "time", "Laboratory studies show", "Serum", "mEq/L Cl", "HCO3", "kg Hemoglobin", "10.5", "Urine", "kg", "following", "most likely explanation", "findings"]}
{"question": "A 38-year-old woman presents to her primary care physician for her yearly exam. Her only complaint is difficulty losing weight. Her BMI is 34 kg/m^2. In addition to a standard physical exam, the physician orders a glucose tolerance test. The woman's fasting blood glucose level is 120 mg/dL and two-hour post 75g glucose load blood glucose level is 190 mg/dL. The physician informs the patient that she is \"pre-diabetic\" or at risk of developing diabetes and recommends lifestyle modification with follow-up in 6 months. Which of the following endogenous signaling molecules or receptors will increase insulin sensitivity in this patient?", "answer": "Peroxisome proliferator-activated receptor gamma", "options": {"A": "Catecholamines", "B": "Glucagon", "C": "Glucocorticoids", "D": "Peroxisome proliferator-activated receptor gamma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "primary care physician", "yearly exam", "only complaint", "difficulty", "weight", "BMI", "kg/m", "standard physical exam", "physician orders", "glucose tolerance test", "woman", "asting blood glucose level ", "g/dL ", "wo- our  ost ", "lucose  oad  lood glucose level ", "g/dL.", "hysician  nforms ", "atient ", "re-diabetic\"", "t ", "iabetes ", "ecommends  ifestyle modification ", "ollow-up ", "onths.", "ollowing  ndogenous  ignaling molecules ", "eceptors ", "ncrease  nsulin sensitivity ", "atient?"]}
{"question": "A 35-year-old male presents to the emergency department for evaluation of hemoptysis. A chest X-ray reveals bilateral focal pulmonary consolidation. On further questioning, he admits having hematuria. Urinalysis shows RBC casts and 400 mL of urine is excreted in 24 hours. What is the most likely cause of hemoptysis and hematuria in this patient?", "answer": "Anti-glomerular basement membrane antibodies", "options": {"A": "Anti-Smith antibodies", "B": "Anti-neutrophil antibodies", "C": "Anti-mitochondrial antibodies", "D": "Anti-glomerular basement membrane antibodies"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old male presents", "emergency department", "evaluation", "hemoptysis", "chest X-ray reveals bilateral focal pulmonary consolidation", "further questioning", "admits", "hematuria", "Urinalysis shows RBC casts", "400 mL", "urine", "excreted", "24 hours", "most likely cause", "hemoptysis", "hematuria", "patient"]}
{"question": "A 34-year-old man comes to the physician with a 2-month history of difficulty concentrating at work. He is worried he may lose his job due to poor performance. He feels constantly tired but attributes his fatigue to waking up early most mornings and being unable to fall back asleep. His wife has noticed that he has been speaking more slowly than usual and his appetite has decreased. He used to enjoy dance classes with her but has not been as interested in this recently. He is a veteran who returned from a deployment to Afghanistan 2 years ago. Which of the following is the most likely diagnosis?", "answer": "Major depressive disorder", "options": {"A": "Major depressive disorder", "B": "Adjustment disorder", "C": "Acute stress disorder", "D": "Post traumatic stress disorder"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "2 month history", "difficulty concentrating", "work", "worried", "job due to poor performance", "feels constantly tired", "attributes", "fatigue", "waking", "early", "mornings", "unable to fall back asleep", "wife", "speaking more slowly", "usual", "appetite", "decreased", "used", "dance classes", "not", "interested", "recently", "veteran", "returned", "deployment", "Afghanistan", "years", "following", "most likely diagnosis"]}
{"question": "A 25-year-old female presents to her primary care physician complaining of double vision. She first started seeing double after a long day at her work as a radiation technologist. Since then, her vision has appeared to worsen in the evenings. She has also felt worsening fatigue despite no change in her work hours or sleep habits. She has a history of type I diabetes mellitus and her most recent hemoglobin A1c was 7.4%. Her family history is notable for Sjogren’s syndrome in her mother and hypertension, hyperlipidemia, and carotid dissection in her father. Her temperature is 98.9°F (37.2°C), blood pressure is 105/70 mmHg, pulse is 75/min, and respirations are 16/min. On examination, her pupils are equally round and reactive to light. Extraocular movements are intact. Mild ptosis is noted bilaterally but worse on the left. A visual acuity test reveals no abnormalities. Which of the following medications is most appropriate in the management of this patient?", "answer": "Pyridostigmine", "options": {"A": "Pyridostigmine", "B": "Physostigmine", "C": "Hydrocortisone", "D": "Azathioprine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female presents", "primary care physician", "double vision", "first started seeing double", "long day", "work", "radiation technologist", "then", "vision", "appeared to worsen", "evenings", "felt worsening fatigue", "change", "work hours", "sleep habits", "history of type I diabetes mellitus", "most recent hemoglobin A1c", "7.4", "family history", "notable", "Sjogrens syndrome", "mother", "hypertension", "hyperlipidemia", "carotid dissection", "father", "temperature", "98 9F", "blood pressure", "70 mmHg", "pulse", "75 min", "respirations", "min", "examination", "pupils", "round", "reactive to light", "Extraocular movements", "intact", "Mild ptosis", "noted", "worse", "left", "visual test reveals", "abnormalities", "following medications", "most appropriate", "management", "patient"]}
{"question": "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?", "answer": "International normalized ratio", "options": {"A": "Echocardiogram", "B": "International normalized ratio", "C": "Partial thromboplastin time", "D": "Serum drug levels"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["76 year old woman visits", "physician", "general medical examination", "asymptomatic", "Six months prior", "stroke with left hemiparesis", "almost completely recovered", "physiotherapy", "history of hypertension", "atrial fibrillation", "significant ischemic", "valvular", "structural heart disease", "takes metoprolol", "amlodipine", "warfarin", "atorvastatin", "Blood pressure", "70 mm Hg", "pulse", "75 min", "irregular rhythm", "Respirations", "min", "minor limp", "weakness", "left", "leg", "Heart exam shows", "abnormalities", "irregular", "To assess adherence", "therapeutic efficacy", "patient", "following studies", "ordered"]}
{"question": "A 4-year-old boy is brought to his primary care physician for a physical prior to beginning a preschool program. He is found to be delayed in reaching normal childhood cognitive and social milestones, which is consistent with observations at previous check-ups. Physically, he is also found to be significantly overweight with hypogonadism. Notably, the boy was limp when he was born and did not have a normal motor response to stimuli. Elevated levels of a gastrointestinal hormone are associated with the cause of this patient's weight gain. The hormone that is most responsible for causing the weight gain is produced in which of the following cell types?", "answer": "P/D1 cells", "options": {"A": "D cells", "B": "G cells", "C": "P/D1 cells", "D": "L cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["4 year old boy", "brought", "primary care physician", "physical prior to beginning", "preschool program", "found to", "delayed", "reaching normal childhood cognitive", "social milestones", "consistent with observations", "previous check-ups", "found to", "overweight", "hypogonadism", "boy", "limp", "born", "not", "normal motor response to stimuli", "Elevated levels", "gastrointestinal hormone", "associated with", "cause", "patient's weight gain", "hormone", "most responsible", "causing", "weight gain", "of", "following cell types"]}
{"question": "Accurate and rapid identification of individuals with tuberculosis (TB) is crucial to accomplishing the goal of the World Health Organization (WHO) to eliminate this disease. One of the key strategies for the detection of TB is the use of tuberculin skin testing as a globally pertinent screening method, due to its low cost and technical simplicity. A study from Brazil demonstrated 76.7% accuracy, 67.9% sensitivity, 84.4% specificity, 79.1% positive predictive value, and 75% negative predictive value when using 5-mm skin elevation as a threshold, or cut-off, point for the screening test (following intradermal injection). Lowering the cut-off point to 4 mm would also result in an increase in which test property?", "answer": "Negative predictive value", "options": {"A": "Convergent validity", "B": "Discriminant validity", "C": "Negative predictive value", "D": "Test specificity"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["Accurate", "rapid identification", "individuals", "tuberculosis", "goal", "World Health Organization", "to", "disease", "One", "strategies", "detection", "TB", "use of tuberculin skin testing", "screening method", "low cost", "technical simplicity", "study", "Brazil", "76", "accuracy", "67", "sensitivity", "84", "specificity", "positive predictive value", "75", "negative predictive value", "using 5-mm skin elevation", "threshold", "cut-off", "point", "screening test", "following intradermal injection", "Lowering", "cut-off point", "mm", "result", "increase", "test property"]}
{"question": "A 55-year-old caucasian male is transferred to a tertiary care hospital from a small county hospital where he presented with jaundice and severe abdominal pain that radiates to the back. While in the county hospital, he did not develop fever, and his vital signs were stable for the 48 hours he spent at there. Initial laboratory tests are given below:\nTotal bilirubin 7 mg/dL\nDirect bilirubin 6.4 mg/dL\nAST 100\nALT 40\nAlkaline phosphatase 480 IU/L\nGlucose 160 mg/dL\nThe patient’s medical history is relevant for hypertension and diabetes mellitus. He admits to smoking cigarettes since his early teenage years. Moderate icterus is evident during physical examination, the abdomen is distended and dull to percussion, and there is periumbilical tenderness. Which of the following markers would you expect to be elevated in this patient?", "answer": "CA 19-9", "options": {"A": "CA 125", "B": "Desmin", "C": "CA 27-29", "D": "CA 19-9"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["55 year old caucasian male", "transferred", "tertiary care hospital", "small county hospital", "presented", "jaundice", "severe abdominal", "radiates", "back", "county hospital", "not", "fever", "vital signs", "stable", "48 hours", "spent", "Initial laboratory tests", "given", "Total bilirubin", "mg dL Direct bilirubin", "dL", "40 Alkaline phosphatase", "IU/L Glucose 160", "patients medical history", "relevant", "hypertension", "diabetes mellitus", "admits", "smoking cigarettes", "early teenage years", "Moderate icterus", "evident", "physical examination", "abdomen", "distended", "dull", "percussion", "periumbilical tenderness", "following markers", "to", "elevated", "patient"]}
{"question": "A one-week-old, full-term infant born by uncomplicated vaginal delivery is brought to a pediatrician by his mother, who notes that her daughter's skin appears yellow. She reports that the child cries several times per day and sleeps 7-8 hours at night, uninterrupted. She has been breastfeeding exclusively and feels that he has been feeding well. Which of the following is the best treatment for this condition?", "answer": "Continue normal breast feeding", "options": {"A": "Phenobarbital administration", "B": "Plasma exchange", "C": "Switch from breast milk to formula", "D": "Continue normal breast feeding"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["one-week old", "full-term infant born", "uncomplicated vaginal", "brought", "pediatrician", "mother", "notes", "daughter's skin appears yellow", "reports", "child cries", "times per day", "sleeps", "8 hours", "night", "breastfeeding", "feels", "feeding well", "following", "best treatment", "condition"]}
{"question": "A 35-year-old woman arrives to the clinic complaining of progressive urinary leakage that has occurred for the past 1 year. At first, she would notice leakage only during athletic exercise, but now the incontinence occurs even when she laughs or coughs. The patient states that she goes to the bathroom more frequently to try to prevent “wetting myself.” She wakes up once a night to urinate. She denies dysuria, hematuria, abdominal pain, and abnormal vaginal discharge. The patient has bipolar syndrome and takes lithium. She had an uncomplicated vaginal delivery 10 years ago and a cesarean section 4 years ago. She has had no other surgeries. She drinks at least 6 glasses of water a day but may drink more on days she goes for a long run. She also has a large coffee in the morning and another coffee mid-day if she “needs to focus.” The patient denies tobacco, alcohol, and other recreational drug use. Pelvic examination and speculum examination are unremarkable. When that patient is asked to Valsalva, leakage of urine is observed. A urinalysis, including specific gravity, is within normal limits. A beta-human chorionic gonadotropin is negative. Which of the following is the most likely cause of the patient’s symptoms?", "answer": "Urethral hypermobility", "options": {"A": "Diabetic polyuria", "B": "Primary polydipsia", "C": "Urethral hypermobility", "D": "Vescicovaginal fistula"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old woman", "clinic", "of progressive urinary leakage", "occurred", "past", "year", "first", "leakage only", "athletic exercise", "now", "incontinence occurs", "laughs", "coughs", "patient states", "goes", "bathroom", "frequently to", "to prevent wetting", "wakes up", "night to", "denies dysuria", "hematuria", "abdominal pain", "abnormal vaginal discharge", "patient", "bipolar syndrome", "takes lithium", "uncomplicated vaginal 10 years", "cesarean section", "years", "surgeries", "drinks", "glasses", "water", "day", "drink more", "days", "goes", "long run", "large coffee", "morning", "coffee", "day", "needs", "focus", "patient denies tobacco", "alcohol", "recreational drug use", "Pelvic examination", "speculum examination", "unremarkable", "patient", "Valsalva", "leakage of urine", "observed", "urinalysis", "including specific gravity", "normal limits", "beta-human chorionic gonadotropin", "negative", "following", "most likely cause", "patients symptoms"]}
{"question": "A 24-year-old woman presents to the emergency department after an episode of altered mental status. She was at a party when she suddenly fell to the floor. Her friends state that she was not responsive and was acting oddly. After the episode, the patient seemed confused and had no memory of the event. The patient has a past medical history of substance abuse, depression, and anxiety. Her temperature is 98.6°F (37.0°C), blood pressure is 117/69 mmHg, pulse is 80/min, respirations are 12/min, and oxygen saturation is 99% on room air. Physical exam reveals a girl who seems confused and responds to questions slowly. Her gait is stable, and she demonstrates 5/5 strength in her upper and lower extremities. Laboratory values and a urine dipstick test are performed as seen below:\n\nToxicology:\nBenzodiazepines: Positive\nMarijuana: Positive\nCocaine: Negative\nPhencyclidine: Negative\n\nUrine Dipstick:\nAppearance: Dark\nRed blood cells: Positive\nGlucose: Negative\n\nWhich of the following is the best next step in management?", "answer": "IV fluids and mannitol", "options": {"A": "Diazepam", "B": "IV fluids and mannitol", "C": "Phenytoin", "D": "Supportive therapy and observation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "episode of altered mental status", "party", "fell", "floor", "friends state", "not responsive", "acting", "episode", "patient", "confused", "memory", "event", "patient", "past history of substance abuse", "depression", "anxiety", "temperature", "98", "blood pressure", "69 mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam reveals", "girl", "confused", "questions slowly", "gait", "stable", "demonstrates 5/5 strength", "upper", "lower extremities", "Laboratory values", "urine dipstick test", "performed", "seen", "Toxicology", "Benzodiazepines", "Positive Marijuana", "Positive Cocaine", "Negative Phencyclidine", "Negative", "Urine Dipstick", "Appearance", "Dark Red blood cells", "Positive Glucose", "Negative", "following", "best next step", "management"]}
{"question": "A 47-year-old woman presents to a physician for evaluation of vomiting and diarrhea for 2 days. Her symptoms began following a company picnic a few days ago. Initially, she was unable to tolerate any solids or liquids by mouth, but now has been able to drink sips of water. She had a mild headache, which was relieved with acetaminophen. The past medical history is unremarkable. She does not take any medications. The blood pressure is 120/60 mm Hg and the heart rate is 60/min. On examination, the mucous membranes are dry and the eyes are slightly sunken. Where is most of the sodium reabsorbed in this patient’s kidneys?", "answer": "Proximal tubule", "options": {"A": "Distal tubule", "B": "Descending limb of loop of Henle", "C": "Proximal tubule", "D": "Ascending limb of loop of Henle"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physician", "evaluation", "vomiting", "diarrhea", "2 days", "symptoms began following", "company", "few days", "Initially", "unable to", "solids", "liquids", "mouth", "now", "able to drink sips", "water", "mild headache", "relieved", "acetaminophen", "past medical history", "unremarkable", "not take", "medications", "blood pressure", "60 mm Hg", "heart rate", "60 min", "examination", "mucous membranes", "dry", "eyes", "slightly", "most", "sodium", "patients kidneys"]}
{"question": "A one-week-old boy presents with yellow sclerae, severe lethargy, and decreased muscle tone. His mother notes that the symptoms started shortly after birth and have been progressively worsening. The patient is breast fed and takes no medications. His labs are within normal limits with the exception of his liver function tests as follows:\n\nALT: 8 U/ L\nAST: 10 U/L\nAlkaline phosphatase: 50 U/L\nAlbumin: 3.7 g/dL\nTotal protein: 6.7 g/dL\nBilirubin, total: 29.4 mg/dL\nBilirubin, unconjugated: 29.2 mg/dL\nBilirubin, conjugated: 0.2 mg/dL\n\nThe boy is taken immediately for treatment. What is the most likely underlying cause of his condition?", "answer": "Absence of UDP-glucuronosyltransferase-1A1", "options": {"A": "Absence of UDP-glucuronosyltransferase-1A1", "B": "Alteration in the ankyrin protein", "C": "Reduction in UDP-glucuronosyltransferase-1A1 activity", "D": "Deficiency in glucocerebrosidase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["one-week old boy presents", "yellow sclerae", "severe lethargy", "decreased muscle tone", "mother notes", "symptoms started", "birth", "worsening", "patient", "breast fed", "takes", "medications", "labs", "normal limits", "exception", "liver function tests", "follows", "ALT", "U", "L AST", "10 U/L Alkaline phosphatase", "50 U/L Albumin", "3", "g/dL Total protein", "g/dL Bilirubin", "total", "29", "mg/dL Bilirubin", "unconjugated", "29", "mg/dL Bilirubin", "conjugated", "0.2 mg/dL", "boy", "taken immediately", "treatment", "most likely underlying cause", "condition"]}
{"question": "A researcher is conducting an experiment on the mouse kidney to study the relative concentrations between the tubular fluid and plasma of a number of substances along the proximal convoluted tubule. Based on the graph shown in figure A, which of the following best describes the tubular fluid-to-plasma concentration ratio of urea?", "answer": "B", "options": {"A": "B", "B": "C", "C": "D", "D": "E"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["researcher", "conducting", "experiment", "mouse kidney to study", "relative concentrations", "tubular fluid", "plasma", "number", "substances", "proximal convoluted tubule", "Based", "graph shown", "following best", "tubular fluid", "plasma ratio", "urea"]}
{"question": "A 62-year-old man comes to the emergency department because of right-sided back pain, nausea, and dark urine. He reports alternating episodes of decreased urine output followed by a temporary increase in urine output for the past 2 days. In the past year, he has had two urinary tract infections. He has Crohn disease and underwent a small bowel resection 5 years ago. He currently takes mesalamine and a multivitamin. His father had recurrent kidney stones. His vital signs are within normal limits. Examination shows right costovertebral angle tenderness. Urinalysis shows 70 RBC/hpf and envelope-shaped crystals. A CT scan of the abdomen shows a 6-mm stone in the proximal right ureter and two 4-mm stones in the left kidney. Which of the following factors has most likely contributed most to this patient’s current condition?", "answer": "Malabsorption of fatty acids", "options": {"A": "Parathyroid gland adenoma", "B": "Excess vitamin D", "C": "Malabsorption of fatty acids", "D": "High urine pH"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["62 year old man", "emergency department", "right-sided back pain", "nausea", "dark urine", "reports alternating episodes of decreased urine output followed by", "temporary increase", "urine output", "past 2 days", "past year", "two urinary tract infections", "Crohn disease", "small bowel resection", "years", "currently takes mesalamine", "multivitamin", "father", "recurrent kidney stones", "vital signs", "normal limits", "Examination shows right costovertebral angle tenderness", "Urinalysis shows 70 RBC/hpf", "envelope shaped crystals", "CT scan", "abdomen shows", "6-mm stone", "proximal right", "two", "mm stones in", "left kidney", "following factors", "most likely contributed most", "patients current condition"]}
{"question": "An 8-year-old boy is brought to the physician because he has excessively dry skin. His mother says that he has had dry, scaly skin since he was 6 months old. She says it is worse in winter and better in summer. There is no associated itching, redness, or discharge. Examination reveals generalized fine scales with coarse skin all over the body, except in the skin creases of the neck and in the cubital and popliteal fossae (see image). There are multiple papular elevations at the base of hair follicles and darkening of the palmar and plantar creases. Which of the following is the most likely diagnosis?", "answer": "Ichthyosis vulgaris", "options": {"A": "Psoriasis", "B": "Lichen simplex", "C": "Ichthyosis vulgaris", "D": "Pityriasis versicolor"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "excessively dry skin", "mother", "dry", "scaly skin", "months old", "worse", "winter", "better", "summer", "associated itching", "redness", "discharge", "Examination reveals generalized fine scales", "coarse skin", "body", "the skin", "of", "neck", "cubital", "popliteal fossae", "see image", "multiple papular elevations", "base", "hair follicles", "palmar", "plantar creases", "following", "most likely diagnosis"]}
{"question": "A 29-year-old woman, gravida 3, para 2, at 24 weeks' gestation comes to the emergency department because of vaginal bleeding and mild pelvic pain for 2 hours. Her current pregnancy was achieved by means of in vitro fertilization due to azoospermia in her partner. Prenatal course has been uncomplicated with regular prenatal visits. After a period of having avoided sexual intercourse during her early pregnancy, she resumed sexual activity with her partner at week 22 of gestation. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other child was delivered vaginally. She has had abnormal Pap smears due to HPV in the past. Her pulse is 82/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. The abdomen is nontender, the uterus is consistent with 24 weeks' gestation, and the fetus is in a cephalic presentation. There are traces of blood on the vulva and the introitus. Speculum examination shows a tender, bruised cervix, with a closed cervical os. Fetal heart rate is 166/min and CTG shows a reassuring fetal heart rate tracing. Ultrasound shows a uniformly echogenic placenta located at the fundal end of the posterior uterine wall. What is the most likely cause of this patient's antepartum bleeding?", "answer": "Cervical trauma", "options": {"A": "Pedunculated cervical growth", "B": "Inflammation of the cervix", "C": "Cervical trauma", "D": "Premature separation of the placenta"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["29 year old woman", "gravida 3", "para 2", "weeks", "gestation", "emergency department", "vaginal bleeding", "mild pelvic", "hours", "current pregnancy", "means", "in vitro fertilization due to azoospermia", "partner", "Prenatal course", "uncomplicated", "regular prenatal visits", "period", "sexual intercourse", "early pregnancy", "resumed sexual", "partner", "week", "gestation", "first child", "delivered", "lower segment transverse cesarean", "fetal heart rate", "child", "delivered", "abnormal due to HPV", "past", "pulse", "min", "respirations", "min", "blood pressure", "76 mm Hg", "abdomen", "nontender", "uterus", "consistent with", "weeks", "gestation", "fetus", "cephalic presentation", "traces", "blood", "vulva", "introitus", "Speculum examination shows", "tender", "bruised cervix", "closed cervical os", "Fetal heart rate", "min", "shows", "reassuring fetal heart rate", "Ultrasound shows", "echogenic placenta", "fundal end of", "posterior uterine wall", "most likely cause", "patient's antepartum bleeding"]}
{"question": "A 16-year-old boy is rushed to the emergency room with acute vomiting and abdominal pain that began earlier today. His parents say that the boy was doing well until two days ago when he told them that he was feeling unwell. He has diabetes and takes insulin but stopped taking it when he began to feel poorly two days ago. His temperature is 37°C (98.6°F), respirations are shallow and rapid with a rate of 33/min, pulse is 107/min, and blood pressure is 101/68 mm Hg. He appears severely dehydrated, showing signs of fatigue, and poor skin turgor. His breath has a fruity smell to it. His blood glucose level is 691 mg/dL. Blood is drawn for labs and the results are given below:\nSerum:  \n  pH: 7.21\n  pCO2: 32 mm HG\n  HCO 3-: 15.2 mEq/L\nSodium: 122 mEq/L\nPotassium: 5.8 mEq/L\nUrinalysis is positive for ketone bodies. What is the most appropriate immediate step in the management of this patient?", "answer": "Administer IV fluids and insulin", "options": {"A": "Administer IV fluids and insulin", "B": "Administer IV antibiotics", "C": "Administer IV fluids with oral antidiabetic medications", "D": "Administer potassium and magnesium"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "rushed", "emergency room", "acute vomiting", "abdominal pain", "began earlier today", "parents", "boy", "well", "two days", "feeling unwell", "diabetes", "takes insulin", "stopped", "began to feel poorly two days", "temperature", "98", "respirations", "shallow", "rapid", "rate", "min", "pulse", "min", "blood pressure", "68 mm Hg", "appears severely dehydrated", "showing signs", "fatigue", "poor skin turgor", "breath", "fruity smell", "blood glucose level", "mg/dL", "Blood", "drawn", "labs", "results", "given", "Serum", "pH", "pCO2", "mm HG", "HCO", "mEq/L Sodium", "mEq/L Potassium", "5.8 mEq/L Urinalysis", "positive", "ketone bodies", "most appropriate immediate step", "management", "patient"]}
{"question": "A 28-year-old male presents to the emergency department with chest pain. He reports that one hour ago he was climbing the stairs in his home when he suddenly developed excruciating chest pain. He describes the pain as ripping and radiating to the back. The patient’s past medical history is significant for a heart murmur that is being followed by his outpatient cardiologist. He takes no medications. The patient works as a carpenter and reports being monogamous with his wife. He denies any history of intravenous drug use or recent travel. In the emergency department, the patient’s temperature is 99.4°F (37.4°C), blood pressure is 94/56 mmHg, pulse is 121/min, and respirations are 14/min. On physical exam, the patient appears to be in moderate distress and is clutching his chest. He is tall and has joint hypermobility. His breath sounds are equal and full bilaterally and has weak distal pulses.\n\nWhich of the following is most likely to be found in this patient?", "answer": "Late systolic crescendo murmur at the apex with mid-systolic click", "options": {"A": "Holosystolic, high-pitched blowing murmur at the lower left sternal border", "B": "Late systolic crescendo murmur at the apex with mid-systolic click", "C": "Mid-diastolic murmur at the left lower sternal border", "D": "Systolic ejection murmur at the right second intercostal space"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old male presents", "emergency department", "chest pain", "reports", "one hour", "climbing", "stairs", "home", "excruciating chest", "pain", "ripping", "radiating to", "back", "patients past medical history", "significant", "heart murmur", "followed by", "outpatient cardiologist", "takes", "medications", "patient works", "carpenter", "reports", "monogamous", "wife", "denies", "history", "intravenous drug use", "recent travel", "emergency department", "patients temperature", "99 4F", "4C", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "physical exam", "patient appears to", "moderate distress", "chest", "tall", "joint hypermobility", "breath sounds", "equal", "full", "weak distal pulses", "following", "most likely to", "found", "patient"]}
{"question": "A mother brings her 6-year-old daughter to the pediatrician to discuss her child's sleeping troubles. Three times now in the last month the child has begun screaming and crying in the middle of the night. When the parents rush to the child's room, they find her crying inconsolably. They try to ask her what is wrong, but she does not respond and persists crying for approximately 20 minutes, after which she goes back to sleeping comfortably. Upon awaking the following morning, she has no recollection of the night's events. Which of the following is true about these episodes?", "answer": "They occur only during non-REM sleep", "options": {"A": "They will be persistent into adulthood", "B": "They occur only during non-REM sleep", "C": "They are associated with child abuse", "D": "They are associated with later development of a mood disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["mother", "year old daughter", "pediatrician to discuss", "child's sleeping troubles", "Three times now", "month", "child", "begun screaming", "crying", "middle", "night", "parents rush", "child's room", "find", "crying", "to", "wrong", "not", "crying", "approximately 20 minutes", "goes back", "sleeping", "awaking", "following morning", "recollection", "night's events", "following", "true", "episodes"]}
{"question": "An 18-year-old woman comes to the physician because of a pruritic rash on her back for the past 2 hours. This morning, she started a course of ceftriaxone for treatment of pyelonephritis. A photograph of the rash is shown. This patient's skin findings are most likely associated with which of the following?", "answer": "Hyperpermeability of superficial dermal microvasculature", "options": {"A": "Direct tissue damage by irradiated antibiotic agent", "B": "Cytotoxic T-cell destruction of antigen-tagged cells", "C": "Hyperpermeability of superficial dermal microvasculature", "D": "Mast cell activation in subcutaneous tissues"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "of", "pruritic rash", "back", "past", "hours", "morning", "started", "course", "ceftriaxone", "treatment", "pyelonephritis", "photograph", "rash", "shown", "patient's skin findings", "most likely associated with"]}
{"question": "Two hours after admission to the hospital for dialysis, a 63-year-old woman has severe pain in her lower back. The pain is 8 out of 10 in intensity and radiates down the legs. She underwent a laparoscopic cholecystectomy 4 years ago. She has hypertension, chronic kidney disease, type 2 diabetes mellitus, and major depressive disorder. She lives with her daughter and reports frequent fights with her at home. Her current medications include sertraline, insulin, enalapril, sodium bicarbonate, and sevelamer. She appears uncomfortable. Her temperature is 37.3°C (99.1°F), pulse is 102/min, respirations are 15/min, and blood pressure is 132/94 mm Hg. There is severe tenderness on palpation over the L2 vertebra; range of motion is limited. Neurologic examination shows no focal findings. Laboratory studies show:\nHemoglobin 10.1 g/dL\nLeukocyte count 8,700/mm3\nPlatelet count 130,000/mm3\nSerum\nNa+ 136 mEq/L\nCl- 101 mEq/L\nK+ 5.1 mEq/L\nCalcium 8.2 mg/dL\nUrea nitrogen 33 mg/dL\nGlucose 190 mg/dL\nCreatinine 3.8 mg/dL\nAn x-ray of the spine shows a wedge compression fracture of the L2 vertebra. Which of the following is the most likely explanation for these findings?\"", "answer": "Secondary hyperparathyroidism", "options": {"A": "Tertiary hyperparathyroidism", "B": "Secondary hyperparathyroidism", "C": "Elder abuse", "D": "Primary hyperparathyroidism"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two hours", "admission", "hospital", "dialysis", "63 year old woman", "severe pain in", "lower back", "pain", "8 out", "10", "intensity", "radiates", "legs", "laparoscopic cholecystectomy", "years", "hypertension", "chronic kidney disease", "type 2 diabetes mellitus", "major depressive disorder", "lives with", "daughter", "reports frequent fights", "home", "current medications include sertraline", "insulin", "enalapril", "sodium bicarbonate", "sevelamer", "appears", "temperature", "3C", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "severe tenderness", "palpation", "L2 vertebra", "range of motion", "limited", "Neurologic examination shows", "focal findings", "Laboratory studies show", "10", "g", "Leukocyte count", "L", "5", "mg", "Urea nitrogen 33 mg", "Creatinine 3", "x-ray of", "spine shows", "wedge compression", "L2", "following", "most likely explanation", "findings"]}
{"question": "A 50-year-old man comes to the physician because of swelling of his legs for 2 months. Three months ago, he was diagnosed with hypertension and started on a new medication. His blood pressure is 145/95 mm Hg. Physical examination shows 2+ edema in both lower extremities. Laboratory studies are within the reference ranges. This patient was most likely treated with which of the following drugs?", "answer": "Amlodipine", "options": {"A": "Losartan", "B": "Spironolactone", "C": "Hydrochlorothiazide", "D": "Amlodipine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["50 year old man", "physician", "of swelling", "legs", "2 months", "Three", "diagnosed", "hypertension", "started", "new medication", "blood pressure", "95 mm Hg", "Physical examination shows 2", "edema", "lower extremities", "Laboratory studies", "reference ranges", "patient", "most likely treated with", "following drugs"]}
{"question": "An investigator is studying the function of different enzymes in various human cell types. A subset of normal human cells with an elevated intracellular concentration of bisphosphoglycerate mutase is harvested and isolated. Which of the following is most likely to be absent in these cells?", "answer": "α-ketoglutarate dehydrogenase", "options": {"A": "α-ketoglutarate dehydrogenase", "B": "Pyruvate kinase", "C": "Glutathione reductase", "D": "Carbonic anhydrase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying", "function", "different enzymes", "various human cell types", "subset", "normal human cells", "elevated intracellular concentration", "bisphosphoglycerate mutase", "harvested", "isolated", "following", "most likely to", "absent", "cells"]}
{"question": "A 28-year-old woman is brought to the emergency room after a motor vehicle accident. On arrival, she is stable and says that she hit a car at an intersection that \"came out of nowhere\". She states that she had similar close encounters with other cars these past few weeks but was able to avoid collisions with those. She has also had intermittent headaches over the last month and has noticed that her shirts have been getting wet unexpectedly. Blood tests reveal an abnormal elevation of a circulating substance. Which of following changes is also associated with the physiologic function of the most likely substance in this case?", "answer": "Decreased progesterone", "options": {"A": "Decreased oxytocin", "B": "Decreased progesterone", "C": "Increased follicle stimulating hormone", "D": "Increased progesterone"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency room", "motor vehicle accident", "arrival", "stable", "hit", "car", "intersection", "out", "states", "similar close encounters", "cars", "past", "weeks", "able to", "collisions", "intermittent headaches", "month", "shirts", "getting wet", "Blood tests reveal", "abnormal elevation", "circulating substance", "following changes", "associated with", "physiologic function", "likely substance", "case"]}
{"question": "A 23-year-old woman comes to the physician because of a 2-month history of episodic headaches associated with dizziness, nausea, and vomiting. Over-the-counter pain medications have failed to reduce her symptoms. An MRI of the brain shows isolated dilation of the left lateral ventricle. This dilatation is most likely caused by blockade of which of the following structures?", "answer": "Interventricular foramen", "options": {"A": "Arachnoid villi", "B": "Interventricular foramen", "C": "Median aperture", "D": "Lateral apertures"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "physician", "of", "2 month history", "episodic headaches associated with dizziness", "nausea", "vomiting", "Over-the-counter pain medications", "failed to", "symptoms", "MRI of", "brain shows isolated dilation of", "left lateral ventricle", "dilatation", "most likely caused", "blockade", "following structures"]}
{"question": "A 20-day-old child is brought to the emergency department by her parents. They are concerned about lethargy and easy bruising. Her mother reports that she has been eating less for the past few days. Today she was difficult to arouse. She normally nurses four-five times a day, but ate less yesterday and this morning. The girl was born at 39 weeks gestation via spontaneous vaginal delivery at home with minimal prenatal or postnatal care. This is her first visit to a physician of any type. The family is carefully questioned and child abuse is ruled out. The daughter’s pulse is 97/min, respirations are 35/min, temperature is 35.8°C (96.4°F), and blood pressure is 71/46 mm Hg. Physical examination shows diffuse petechiae and bruising. Which of the following is the most likely cause?", "answer": "Vitamin K deficiency", "options": {"A": "Group B streptococcus (GBS) infection", "B": "Hepatitis B infection", "C": "Thyroid stimulating hormone deficiency", "D": "Vitamin K deficiency"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["20 day old child", "brought", "emergency department", "parents", "concerned", "lethargy", "easy bruising", "mother reports", "eating less", "past", "days", "Today", "difficult", "nurses four five times", "day", "ate less", "morning", "girl", "born", "weeks gestation", "spontaneous vaginal delivery at home", "minimal prenatal", "postnatal care", "first visit", "physician", "type", "family", "questioned", "child abuse", "ruled out", "daughters pulse", "97 min", "respirations", "35 min", "temperature", "35", "96 4F", "blood pressure", "71", "mm Hg", "Physical examination shows diffuse petechiae", "bruising", "following", "most likely cause"]}
{"question": "A 10-year-old boy is brought to the physician because of a generalized, non-itchy rash for 2 days. He has also had a fever and sore throat for 4 days. He has not received any routine childhood vaccinations. Examination shows a flushed face except around his mouth. A diffuse, papular, erythematous rash that blanches with pressure is seen over the trunk. Pharyngeal erythema and a red beefy tongue are noted. His leukocyte count is 11,200/mm3 (75% segmented neutrophils, 22% lymphocytes). Without treatment, this patient's current condition puts him at greatest risk for which of the following complications?", "answer": "Mitral valve regurgitation", "options": {"A": "Coronary artery aneurysms", "B": "Encephalitis", "C": "Mitral valve regurgitation", "D": "Minimal change disease"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A 10 year old boy", "brought", "physician", "of", "generalized", "non itchy", "2 days", "fever", "sore throat", "4 days", "not received", "routine childhood vaccinations", "Examination shows", "flushed face", "mouth", "diffuse", "papular", "erythematous", "blanches", "pressure", "seen", "trunk", "Pharyngeal", "red beefy tongue", "noted", "leukocyte count", "200 mm3", "75", "segmented neutrophils", "lymphocytes", "treatment", "patient's current condition puts", "greatest risk", "following complications"]}
{"question": "A 32-year-old man presents to the emergency department with fever, nausea, and vomiting. The patient states that his symptoms started last night and have persisted to this morning. He has a past medical history of asthma, and his current medications include albuterol and fluticasone. His temperature is 102°F (38.9°C), blood pressure is 110/60 mmHg, pulse is 95/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, the patient seems uncomfortable. He requests that the lights in the room stay turned off during the physical exam. The patient's cardiac exam demonstrates a normal rate and rhythm, and his pulmonary exam is clear to auscultation bilaterally. Musculoskeletal exam reveals diminished mobility of the neck in all four directions, with flexion of the neck causing the patient discomfort. Lumbar puncture is performed and results are seen below.\n\nCerebrospinal fluid (CSF):\nCell count: 175/mm^3\nCl-: 119 mEq/L\nGlucose: 49 mg/dL\nPressure: 150 mmH2O\nTotal protein: 55 mg/dL\n\nWhich of the following is the best treatment for this patient's most likely diagnosis?", "answer": "IV fluids and monitoring", "options": {"A": "Acyclovir", "B": "Amphotericin and 5-flucytosine", "C": "Ceftriaxone and vancomycin", "D": "IV fluids and monitoring"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "fever", "nausea", "vomiting", "patient states", "symptoms started last night", "morning", "past medical", "current medications include albuterol", "fluticasone", "temperature", "blood pressure", "60 mmHg", "pulse", "95 min", "respirations", "min", "oxygen saturation", "98", "room air", "physical exam", "patient", "requests", "lights", "room", "turned", "physical exam", "patient's cardiac exam demonstrates", "normal rate", "rhythm", "pulmonary exam", "clear", "auscultation", "Musculoskeletal exam reveals diminished mobility", "neck", "four directions", "flexion", "neck causing", "patient discomfort", "Lumbar puncture", "performed", "results", "seen", "Cerebrospinal fluid", "Cell count", "mm", "Cl", "mEq/L Glucose", "mg/dL Pressure", "mmH2O Total protein", "55 mg/dL", "following", "best treatment", "patient's", "likely diagnosis"]}
{"question": "A 64-year-old man comes to the physician with a 1-week history of sore mouth. He says that swallowing is not painful. He has had asthma for more than 20 years. His only medication is a high-dose combination salmeterol/fluticasone inhaler. His temperature is 37.1°C (98.8°F), pulse is 74/min, respirations are 14/min, and blood pressure is 125/65 mm Hg. A photograph of his oral mucosa is shown. Indirect mirror examination of the posterior oropharynx, larynx, and hypopharynx shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Nystatin", "options": {"A": "Fluconazole", "B": "Isotretinoin", "C": "Nystatin", "D": "Penicillin V"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["64 year old man", "physician", "1-week history", "sore mouth", "swallowing", "not painful", "asthma", "20 years", "only medication", "high-dose combination salmeterol/fluticasone inhaler", "temperature", "98", "pulse", "74 min", "respirations", "min", "blood pressure", "65 mm Hg", "photograph", "oral mucosa", "shown", "Indirect mirror examination", "posterior oropharynx", "larynx", "hypopharynx shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 56-year-old woman is brought to the emergency department because of a 2-day history of fever, chills, nausea, and flank pain. She has multiple sclerosis and a chronic indwelling bladder catheter for neurogenic bladder dysfunction. One week ago, she was discharged from the hospital after treatment for a multiple sclerosis flare. Her temperature is 39.3°C (102.8°C). Physical examination shows marked tenderness in the right costovertebral area. Urine cultures grow a non-lactose fermenting, oxidase-positive, gram-negative rod. The causal organism of this patient's current condition most likely produces which of the following substances?", "answer": "Pyoverdine", "options": {"A": "Lipoteichoic acid", "B": "K capsule", "C": "Toxin B", "D": "Pyoverdine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "2-day history", "fever", "chills", "nausea", "flank pain", "multiple sclerosis", "chronic indwelling bladder catheter", "neurogenic", "dysfunction", "One week", "discharged from", "hospital after treatment", "multiple sclerosis flare", "temperature", "3C", "Physical examination shows marked tenderness", "right", "area", "Urine cultures", "non lactose", "oxidase positive", "gram-negative rod", "causal organism", "patient's current condition", "likely", "following substances"]}
{"question": "A 26-year-old man comes to the physician for episodic fever, recurrent night sweats, and a 6-kg (14.2-lb) weight loss over the past 2 months. He reports that the fever lasts for 7 to 10 days, then subsides completely for about a week before returning again. His temperature is 39°C (102.2°F). Physical examination shows nontender cervical and supraclavicular lymphadenopathy. An x-ray of the chest shows bilateral mediastinal masses. Resection of a cervical lymph node is performed. A photomicrograph of the resected specimen is shown. Further histopathological examination is most likely to show which of the following findings?", "answer": "Cells staining positive for CD15 and CD30", "options": {"A": "Cells staining positive for CD15 and CD30", "B": "Cells with BCR-ABL rearrangement", "C": "Cells overexpressing Bcl-2", "D": "Cells with t(8;14) chromosomal translocation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "episodic fever", "recurrent night sweats", "kg", "weight loss", "past", "months", "reports", "fever", "10 days", "then", "completely", "week", "returning", "temperature", "Physical examination shows nontender cervical", "supraclavicular lymphadenopathy", "x-ray of", "chest shows bilateral mediastinal", "Resection", "cervical lymph node", "performed", "photomicrograph", "resected specimen", "shown", "Further histopathological examination", "most likely to show", "following findings"]}
{"question": "A 25-year-old woman comes to the physician for the evaluation of nausea for the last two weeks. During this period, she has had increased urinary frequency and fatigue. She also reports two episodes of non-bloody vomiting. There is no personal history of serious illness. Her last menstrual period was 6 weeks ago. Physical examination shows bilateral breast tenderness. The remainder of the examination shows no abnormalities. A urine pregnancy test is positive. Which of the following is the most accurate predictor of the gestational age?", "answer": "Crown-rump length", "options": {"A": "Ratio of head to abdominal circumference", "B": "Femoral length", "C": "Crown-rump length", "D": "Biparietal length"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "evaluation", "nausea", "last two weeks", "period", "increased urinary frequency", "fatigue", "reports two episodes of non bloody vomiting", "personal history", "serious illness", "last menstrual period", "weeks", "Physical examination shows bilateral", "examination shows", "abnormalities", "urine pregnancy test", "positive", "following", "most accurate predictor", "gestational age"]}
{"question": "A 6-week-old male infant is brought to the physician by his mother because of a 2-day history of recurrent nonbilious vomiting. Vomiting occurs almost immediately after most feeds. Each time, he becomes irritable while feeding and refuses to finish the bottle. He was born at 37 weeks' gestation and weighed 3300 g (7 lb 4 oz); he currently weighs 4000 g (8 lb 13 oz). He has Down syndrome. His vaccinations are up-to-date. He appears agitated and cries during the examination. His temperature is 37.2°C (99°F), pulse is 156/min, respirations are 32/min, and blood pressure is 100/49 mm Hg. Examination shows upward slanting of the eyelids, a broad and flat nasal bridge, and a single transverse palmar crease on both hands. The abdomen is soft and nontender. A 2.5-cm (1-inch) epigastric mass is palpated. Cardiac examination shows no abnormalities. Arterial blood gas analysis is within normal limits. Further diagnostic evaluation of the patient is most likely to show which of the following?", "answer": "Elongated and thickened pylorus on abdominal ultrasound", "options": {"A": "Dilated colon segment on abdominal x-ray", "B": "Detection of rotavirus antigen on enzyme immunoassay (EIA)", "C": "Elongated and thickened pylorus on abdominal ultrasound", "D": "Tripple bubble sign on abdominal x-ray"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["week old male infant", "brought", "physician", "mother", "2-day history", "recurrent", "vomiting", "Vomiting occurs almost immediately", "feeds", "time", "irritable", "feeding", "refuses to finish", "bottle", "born", "weeks", "gestation", "3300 g", "oz", "currently", "4000 g", "8", "oz", "Down syndrome", "vaccinations", "date", "appears agitated", "cries", "examination", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "100", "mm Hg", "Examination shows upward", "eyelids", "broad", "flat nasal bridge", "single transverse palmar crease", "hands", "abdomen", "soft", "nontender", "2.5", "1-inch", "epigastric mass", "palpated", "Cardiac examination shows", "abnormalities", "Arterial blood gas analysis", "normal limits", "Further diagnostic", "patient", "most likely to show", "following"]}
{"question": "A 5-year-old Syrian immigrant and her family present for an immigration physical. Her mother describes photophobia, bilateral lacrimation, eye itching, and eyelid swelling for the last week. She is known to have an allergy to cephalosporins. She was born at 39 weeks gestation via spontaneous vaginal delivery. She has met all of her developmental milestones and most of her vaccines. Her vital signs are as follows: blood pressure 105/60 mm Hg, heart rate 98/min, respiratory rate 18/min, and temperature 37.0°C (98.6°F). The physical examination is mostly normal except for her eye exam as presented in the image below. Which of the following statements is true regarding treatment of this patient’s condition?", "answer": "The child should be administered a single dose of oral azithromycin.", "options": {"A": "A third-generation cephalosporin would be the best treatment option in case the child did not have an actual allergy.", "B": "The child should be treated with topical bacitracin.", "C": "The best treatment option is oral tetracycline.", "D": "The child should be administered a single dose of oral azithromycin."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old Syrian immigrant", "family present", "immigration physical", "mother", "photophobia", "bilateral lacrimation", "eye itching", "eyelid swelling", "week", "known to", "allergy", "cephalosporins", "born", "weeks gestation", "spontaneous vaginal delivery", "met", "developmental milestones", "most", "vaccines", "vital signs", "follows", "blood pressure", "60 mm Hg", "heart rate 98 min", "respiratory rate", "min", "temperature", "98", "physical examination", "mostly normal", "eye exam", "presented", "image", "following statements", "true", "treatment", "patients"]}
{"question": "Three days after induction chemotherapy, a 9-year-old boy is admitted to the hospital for fever and neutropenia. He was initially diagnosed with t(9;22)-positive acute T cell lymphoblastic leukemia following workup for fatigue and pancytopenia. He is fully conscious. His blood pressure is 110/65 mm Hg, temperature is 39.5°C (103.1°F), pulse is 98/min, and respiratory rate is 14/min. Physical examination including examination of the central venous catheter site shows no source of infection. Broad-spectrum antibiotics are initiated. Which of the following factors about this patient most strongly indicates a poor prognosis?", "answer": "Cytogenetics", "options": {"A": "Age", "B": "Cytogenetics", "C": "Fever and neutropenia", "D": "Initial presentation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Three days", "induction chemotherapy", "year old boy", "admitted", "hospital", "fever", "neutropenia", "initially diagnosed", "positive acute T cell lymphoblastic leukemia following workup", "fatigue", "pancytopenia", "fully conscious", "blood pressure", "65 mm Hg", "temperature", "pulse", "98 min", "respiratory rate", "min", "Physical examination including examination of", "central venous shows", "source of infection", "Broad spectrum antibiotics", "initiated", "following factors", "patient", "poor prognosis"]}
{"question": "A 45-year-old homeless man comes to the emergency department because of progressive neck pain for 3 days. He also reports headaches and numbness in both hands. Over the past 4 months, he has had intermittent lower back pain after waking up. The back pain improves with movement. He also has recurrent episodes of gout in the metatarsophalangeal joint of his right big toe. He has smoked one pack of cigarettes daily for 20 years and drinks four beers daily. The patient is a known user of intravenous heroin. He appears acutely ill. His temperature is 39°C (102.2°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. There are several track marks on both forearms. Examination of the neck shows warmth, erythema, and limited range of motion. Gentle palpation over the midcervical spinal processes causes severe pain. Laboratory studies show:\nHemoglobin 11 g/dL\nLeukocyte count 14,200/mm3\nSegmented neutrophils 77%\nEosinophils 1%\nLymphocytes 20%\nMonocytes 2%\nPlatelet count 278,000/mm3\nErythrocyte sedimentation rate 54 mm/h\nBlood cultures are pending. An x-ray of the cervical spine shows no abnormalities. An MRI of the spine shows signs of inflammation. A bone biopsy confirms the diagnosis. Which of the following is the most appropriate next step in management?\"", "answer": "Intravenous ciprofloxacin and vancomycin therapy", "options": {"A": "Lumbar puncture", "B": "Intravenous ciprofloxacin and vancomycin therapy", "C": "Oral indomethacin therapy", "D": "Bone scintigraphy\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old homeless man", "emergency department", "of progressive neck pain", "3 days", "reports headaches", "numbness", "hands", "past", "months", "intermittent lower back pain", "waking", "back pain improves", "movement", "recurrent episodes of gout", "metatarsophalangeal joint of", "right big toe", "smoked one pack", "cigarettes daily", "20 years", "drinks four beers daily", "patient", "known user", "intravenous heroin", "appears", "ill", "temperature", "pulse", "min", "blood pressure", "85 mm Hg", "several track marks", "forearms", "Examination of", "neck shows warmth", "erythema", "limited range of motion", "Gentle palpation", "spinal processes causes severe pain", "Laboratory studies show", "Hemoglobin", "g", "Leukocyte count", "200 mm3", "neutrophils", "2", "Platelet count", "Erythrocyte sedimentation rate 54 mm/h Blood cultures", "x-ray of", "cervical spine shows", "abnormalities", "MRI of", "spine shows signs", "inflammation", "bone biopsy confirms", "diagnosis", "following", "most appropriate next step", "management"]}
{"question": "A 1-month-old girl is brought to the emergency department with persistent vomiting, dehydration, and irritability. Over the past week, she has been projectile vomiting after most feedings. Initially, the vomiting would occur just once or twice a day, but now it occurs after every feed. However, her appetite hasn’t decreased, and she seeks milk right after each episode of vomiting. She was born at 39 weeks gestation via spontaneous vaginal delivery and is breastfed exclusively. On physical exam, the vital signs include: temperature 37.5°C (99.5°F), blood pressure 85/55 mm Hg, respiratory rate 28/min, and heart rate 150/min. On examination, she appears to be mildly dehydrated, listless, and irritable. Her abdomen is soft and nontender with a palpable olive-shaped mass in the epigastric region. Which of the following acid-base disturbances is most likely associated with this patient’s condition?", "answer": "Metabolic alkalosis", "options": {"A": "Respiratory alkalosis", "B": "Metabolic alkalosis", "C": "Respiratory acidosis", "D": "Mixed respiratory and metabolic acidosis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old girl", "brought", "emergency department", "persistent vomiting", "dehydration", "irritability", "past week", "projectile vomiting", "feedings", "Initially", "vomiting", "occur", "twice a day", "now", "occurs", "feed", "appetite hasnt decreased", "milk right", "episode of vomiting", "born", "weeks gestation", "spontaneous vaginal delivery", "breastfed", "physical exam", "vital signs include", "temperature", "99", "blood pressure 85 55 mm Hg", "respiratory rate", "min", "heart rate", "min", "examination", "appears to", "mildly dehydrated", "listless", "irritable", "abdomen", "soft", "nontender", "palpable olive shaped mass", "epigastric region", "following acid base disturbances", "most likely associated with", "patients condition"]}
{"question": "A 10-year-old girl is brought to a clinic by her parents after 1 week of difficulty breathing, dry cough, and low-grade fevers. She has also developed shallow erythematous ulcers inside of her mouth. There is no history of chills, rigors, or headaches. Her appetite has decreased. The girl has been HIV-positive since birth and is being treated with HAART. Her baseline viral load is <50/mL. On general examination, the girl appears ill. Diffuse inspiratory crackles are heard on chest auscultation with normal heart sounds. No lymphadenopathy or hepatosplenomegaly is noted on physical examination. A blood sample is drawn, which shows a CD4 count of 100/mm3 and a viral load of 25,050/mL. What is the most likely mechanism responsible for the lack of responsiveness to therapy?", "answer": "pol gene mutation", "options": {"A": "Ineffective CD8 cytotoxicity", "B": "env gene mutation", "C": "pol gene mutation", "D": "Decreased viral replication"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["A 10 year old girl", "brought", "clinic", "parents", "1 week", "difficulty breathing", "dry cough", "low-grade fevers", "shallow erythematous ulcers", "of", "mouth", "history", "chills", "rigors", "headaches", "appetite", "decreased", "girl", "HIV-positive", "birth", "treated with HAART", "baseline viral load", "50 mL", "general examination", "girl appears ill", "Diffuse inspiratory crackles", "heard", "chest auscultation", "normal heart sounds", "lymphadenopathy", "hepatosplenomegaly", "noted", "physical examination", "blood sample", "drawn", "shows", "CD4 count", "100 mm3", "viral load", "mL", "most likely mechanism responsible", "lack", "responsiveness", "therapy"]}
{"question": "A 68-year-old man presents to the emergency department with confusion. The patient lives in a nursing home and has Alzheimer dementia at baseline. His nurse noticed that he was more confused than usual and was somnolent for the past 12 hours. The patient’s nurse also noticed that he was soiling his diapers more frequently with copious amounts of urine. The patient has lost 15 pounds since his last physician appointment 3 weeks ago. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 12.2 mg/dL\nPTH: 8 pg/mL\n\nThe patient is referred to another physician for a more thorough workup including laboratory work and CT imaging. Which of the following is the best long-term prophylaxis for the cause of this patient’s acute symptoms?", "answer": "Alendronate", "options": {"A": "Alendronate", "B": "Calcitonin", "C": "IV fluids", "D": "Teriparatide"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["68 year old man presents", "emergency department", "confusion", "patient lives in a nursing home", "Alzheimer dementia", "baseline", "nurse", "more confused", "usual", "somnolent", "past 12 hours", "patients nurse", "soiling", "diapers", "frequently", "copious amounts", "urine", "patient", "lost", "pounds", "last physician appointment", "weeks", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL Ca2", "mg/dL", "pg/mL", "patient", "referred", "physician", "more", "workup including laboratory work", "CT imaging", "following", "best long-term prophylaxis", "cause", "patients acute symptoms"]}
{"question": "A 68-year-old woman is referred to the outpatient psychiatry clinic from the medical clinic. The patient is being treated for urge incontinence but is being referred for psychiatric evaluation to help with some of her old avoidance behavior. For the 3 months that she had her urinary symptoms, she avoided places like long lines and long train rides. Even after being successfully treated for her urinary condition, she continues to show restricted social interaction. Which of the following is a true statement regarding the patient's condition?", "answer": "She fears not being able to escape similar situations.", "options": {"A": "She fears not being able to escape similar situations.", "B": "Her symptoms need to last for at least 1 month.", "C": "She requires only one fear or avoidance situation to meet criteria for this condition.", "D": "Patients may have accompanying social phobia."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["68 year old woman", "referred", "outpatient psychiatry clinic", "medical clinic", "patient", "treated", "urge incontinence", "referred", "psychiatric evaluation to help", "old avoidance behavior", "3 months", "urinary symptoms", "places", "long lines", "long train", "treated", "urinary condition", "continues to show restricted social interaction", "following", "true statement", "patient's condition"]}
{"question": "A 55-year-old male presents to the emergency department with dyspnea and palpitations. He does not smoke cigarettes or consume alcohol, and past medical history is insignificant. Blood pressure is 115/75 mmHG and heart rate is 125/min. Heart rhythm is irregularly irregular. After initial treatment with IV digoxin the patient's heart rate drops to 85/min and remains irregular. Which of the following best explains the effect of digoxin in this patient?", "answer": "Vagal stimulation", "options": {"A": "Blockade of beta-adrenergic receptors", "B": "Calcium channel blockade", "C": "Vagal stimulation", "D": "Increased ventricular contractility"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["55 year old male presents", "emergency department", "dyspnea", "palpitations", "not smoke cigarettes", "alcohol", "past medical history", "Blood pressure", "75 mmHG", "heart rate", "min", "Heart rhythm", "irregular", "initial treatment", "IV digoxin", "patient's heart rate drops", "85 min", "irregular", "following best", "effect", "digoxin", "patient"]}
{"question": "Public health researchers are reviewing data from an outbreak of hepatitis A that was traced to contaminated produce from a popular restaurant. A case series investigation with prospective and retrospective follow-up found that 500 individuals dined at the restaurant during the week of study. The incidence of hepatitis A infection was found to be 25%, and the total number of deaths recorded among the incident cases was 5 individuals. What was the case-fatality rate for the hepatitis A outbreak?", "answer": "4%", "options": {"A": "4%", "B": "10%", "C": "20%", "D": "25%"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["Public health researchers", "reviewing data", "outbreak", "hepatitis A", "traced", "contaminated", "popular restaurant", "case series investigation", "prospective", "retrospective follow-up found", "500 individuals dined", "restaurant", "week", "study", "incidence", "hepatitis A infection", "found to", "total number", "deaths recorded", "incident cases", "5 individuals", "case-fatality rate", "hepatitis A outbreak"]}
{"question": "A 30-year-old man is brought to the emergency room by ambulance after being involved in a motor vehicle collision. He was driving a motorcycle and collided with a bus. The EMT personnel found the patient alert with anterograde amnesia for the several minutes preceding the accident. Vital signs are within normal limits. On physical examination, the patient is drowsy but follows commands. Pupils are equal, round, and reactive to light. The remainder of the initial examination is unremarkable. While the patient is being transferred to observation, his level of consciousness acutely declines. Repeat vital signs are significant for a blood pressure of 190/110 mm Hg. Ophthalmic examination now shows a fixed and dilated left pupil with no pupillary light reflex. A noncontrast CT of the head is performed and is shown in the image. Which of the following is the most likely etiology of this patient’s condition?", "answer": "Tearing of the middle meningeal artery", "options": {"A": "Tearing of the middle meningeal artery", "B": "Dural arteriovenous fistula", "C": "Charcot-Bouchard microaneurysm", "D": "Arteriovenous malformation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["30 year old man", "brought", "emergency room", "ambulance", "involved", "motor vehicle collision", "driving", "motorcycle", "bus", "EMT personnel found", "patient alert", "anterograde amnesia", "several minutes preceding", "accident", "Vital signs", "normal limits", "physical examination", "patient", "drowsy", "follows commands", "Pupils", "equal", "round", "reactive to light", "initial examination", "unremarkable", "patient", "transferred", "observation", "level of consciousness", "Repeat vital signs", "significant", "blood pressure of", "mm Hg", "Ophthalmic examination now shows", "fixed", "dilated left pupil", "pupillary light reflex", "CT of", "head", "performed", "shown", "image", "following", "most likely etiology", "patients condition"]}
{"question": "A 42-year-old man presents to his primary care physician for a follow-up visit. He has type 1 diabetes mellitus, for which he takes insulin. He complains of frequent episodes of waking up in the middle of his sleep. When he wakes up, he feels excessive sweating, hand tremors, and weakness. His morning blood glucose is high on repeated measurement. Which of the following is the optimal intervention for this patient condition?", "answer": "Reducing daily insulin dose", "options": {"A": "Reassurance", "B": "Adding pramlintide", "C": "Increasing daily insulin dose", "D": "Reducing daily insulin dose"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician", "follow-up visit", "type 1 diabetes mellitus", "takes insulin", "of frequent episodes", "waking", "middle", "sleep", "wakes up", "feels excessive sweating", "hand tremors", "weakness", "morning blood glucose", "high", "repeated measurement", "following", "optimal intervention", "patient condition"]}
{"question": "A researcher conducts multiple experiments to establish an infection and disease model for Clostridium perfringens in chickens. To ensure that all instruments are free of the pathogenic organism, he uses a disinfectant that oxidizes and denatures proteins. Which of the following disinfectants did the researcher most likely use?", "answer": "Chlorine dioxide", "options": {"A": "Chlorine dioxide", "B": "Isopropyl alcohol", "C": "Povidone-iodine", "D": "Benzalkonium chloride"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["researcher conducts multiple experiments to establish", "infection", "disease model", "Clostridium perfringens", "chickens", "To ensure", "instruments", "free", "pathogenic organism", "uses", "disinfectant", "oxidizes", "proteins", "following disinfectants", "researcher", "likely use"]}
{"question": "A 23-year-old woman visits her obstetrician for an antenatal appointment. She is at the 24th week of gestation. She has had type 1 diabetes mellitus for 5 years and is on insulin. She also has mitral stenosis, for which she has been advised to undergo a balloon valvotomy. Her temperature is 37.1°C (98.7°F), blood pressure is 120/60 mm Hg, and pulse is 90/minute. Her random blood glucose is 220 mg/dL and HbA1C is 8.5%. She wants to discuss possible complications concerning her pregnancy. Which of the following cardiac complications is her infant at high risk for?", "answer": "Transient hypertrophic cardiomyopathy", "options": {"A": "Hypertrophic obstructive cardiomyopathy", "B": "Transient hypertrophic cardiomyopathy", "C": "Tetralogy of Fallot", "D": "Mitral valve prolapse"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman visits", "obstetrician", "antenatal appointment", "week", "gestation", "type 1 diabetes mellitus", "5 years", "insulin", "mitral stenosis", "to", "balloon valvotomy", "temperature", "98", "blood pressure", "60 mm Hg", "pulse", "90 minute", "random blood glucose", "mg/dL", "8.5", "to discuss possible complications concerning", "pregnancy", "following cardiac complications", "infant", "high risk"]}
{"question": "A 63-year-old man presents to the physician with a complaint of back pain for the past 2 months. The pain is present throughout the day, and even at night when he lies down. He also complains of difficulty walking upstairs and says he recently started to wear adult diapers because he seems to have difficulty controlling his bowel movements. His vital signs are within normal limits. The neurological examination revealed bilateral lower limb weakness, diminished temperature sensation, and decreased vibratory sense. The rectal examination revealed a hard nodular mass and a weak rectal sphincter tone. Which of the following is the most likely cause of his symptoms?", "answer": "Spinal metastasis", "options": {"A": "Syringomyelia", "B": "Spinal metastasis", "C": "Herniated disc", "D": "Spinal hematoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old man presents", "physician", "complaint of back pain", "past", "months", "pain", "present", "day", "night", "difficulty", "recently started to", "adult diapers", "to", "difficulty controlling", "bowel movements", "vital signs", "normal limits", "neurological examination revealed bilateral lower limb weakness", "diminished temperature", "decreased vibratory sense", "rectal examination revealed", "hard nodular mass", "weak rectal sphincter tone", "following", "most likely cause", "symptoms"]}
{"question": "An 18-year-old college student presents to the student health clinic complaining of excessive sleepiness. He first noticed the daytime sleepiness about a year ago but reports that it significantly worsened once he started college. He reports that he goes to bed around 9 p.m. and wakes up for class at 8 a.m.. He naps between classes for a total of 4 hours during the day. Despite this, he wakes up feeling exhausted. He easily falls asleep during class and while studying. This has started to affect both his academics and his social life. On weekends, he can sleep up to 20 hours a day. He reports 2 recent episodes of sudden generalized body weakness along with ptosis and difficulty speaking that occurred after he became angry. Each episode lasted about 10 seconds, but he says he felt back to normal within 15 minutes without any persistent deficits. His Epworth Sleepiness Scale score is 17. Which of the following is the best next step in therapy?", "answer": "Modafinil", "options": {"A": "Clomipramine", "B": "Dextroamphetamine", "C": "Modafinil", "D": "Sleep deprivation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old college student presents", "student health clinic", "excessive sleepiness", "first", "daytime sleepiness", "year", "reports", "worsened", "started college", "reports", "goes", "bed", "m", "wakes up", "class", "8", "m", "naps", "classes", "total", "hours", "day", "wakes up feeling exhausted", "easily falls asleep", "class", "studying", "started to affect", "academics", "social life", "weekends", "sleep", "20 hours", "day", "reports 2 recent episodes of sudden generalized body weakness", "ptosis", "difficulty speaking", "occurred", "angry", "episode lasted", "10 seconds", "felt back", "normal", "15 minutes", "persistent deficits", "Epworth Sleepiness Scale score", "following", "best next step", "therapy"]}
{"question": "A 63-year-old woman with end-stage renal disease complains of feeling lightheaded after her hemodialysis sessions for the past month. She worries she might eventually lose her balance and fall. She has had diabetes mellitus for 22 years. Her medications include folic acid, vitamin B12, amlodipine, and erythropoietin. At the clinic, her blood pressure is 135/80 mm Hg when lying down before dialysis and 110/55 mm Hg when seated after hemodialysis. Cardiopulmonary examination shows no abnormal findings. Laboratory studies after hemodialysis show a Hb of 10.5 mg/dL, a blood sugar of 189 mg/dL, and a hemoglobin A1C of 7.1%. To reduce the likelihood of falls, the most appropriate management is which of the following?", "answer": "Cooling the dialysate", "options": {"A": "Cooling the dialysate", "B": "Eating heavier meals during dialysis", "C": "Increasing ultrafiltration", "D": "Steroid administration"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old woman", "end-stage renal disease", "feeling lightheaded", "hemodialysis sessions", "past month", "worries", "balance", "fall", "diabetes mellitus", "years", "medications include folic acid", "vitamin B12", "amlodipine", "erythropoietin", "clinic", "blood pressure", "80 mm Hg", "lying", "dialysis", "55 mm Hg", "seated", "hemodialysis", "Cardiopulmonary examination shows", "abnormal findings", "Laboratory studies", "hemodialysis show", "Hb", "10 mg/dL", "blood sugar", "mg/dL", "hemoglobin A1C", "To", "likelihood", "falls", "most appropriate management", "following"]}
{"question": "A 34-year-old woman presents to the emergency room with a fever. She developed worsening malaise and diaphoresis over the past 48 hours. Her maximum temperature was 102°F (38.9°C) taken the night before presentation. Her past medical history is notable for major depressive disorder, obesity, fibromyalgia, and severe tension headaches. She previously took paroxetine for a 2-month trial but switched to citalopram 6 months ago as she did not feel like paroxetine was adequately helping her symptoms. Her mood has been stable on her current dose of citalopram. She takes ibuprofen for her headaches but previously borrowed a friend’s headache medication when her headaches became very severe. Of note, she has been trying to lose weight and recently started taking an amino acid supplement at the suggestion of her nephew who is a nutritionist. She is also trying out a new low-carbohydrate diet. She works as a nurse at a local primary care clinic. Her temperature is 101.5°F (38.6°C), blood pressure is 144/80 mmHg, pulse is 108/min, and respirations are 22/min. She is diaphoretic and shivering. Patellar and brachioradialis reflexes are 3+ bilaterally. Tone is increased in her bilateral upper and lower extremities. Rapid dorsiflexion of her right ankle elicits 3 beats of clonus. Pupils are equally round and reactive to light. A basic metabolic panel is within normal limits. Which of the following is the most likely inciting factor for this patient’s condition?", "answer": "Increased tryptophan intake", "options": {"A": "Decreased carbohydrate intake", "B": "Increased tryptophan intake", "C": "Medication change", "D": "Surreptitious opiate abuse"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency room", "fever", "worsening malaise", "diaphoresis", "past 48 hours", "maximum temperature", "taken", "night", "presentation", "past medical history", "notable", "major depressive disorder", "obesity", "fibromyalgia", "severe tension headaches", "took paroxetine", "2 month trial", "switched to citalopram", "months", "not feel", "paroxetine", "helping", "symptoms", "mood", "stable", "current dose", "citalopram", "takes ibuprofen", "headaches", "friends headache medication", "headaches", "very severe", "note", "to", "weight", "recently started taking", "amino acid supplement", "suggestion", "nephew", "nutritionist", "out", "new low-carbohydrate diet", "works", "nurse", "local primary care clinic", "temperature", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "diaphoretic", "shivering", "Patellar", "brachioradialis reflexes", "3", "Tone", "increased", "bilateral upper", "lower extremities", "Rapid dorsiflexion of", "right ankle elicits 3", "clonus", "Pupils", "round", "reactive to light", "basic metabolic panel", "normal limits", "following", "most likely", "factor", "patients condition"]}
{"question": "A 47-year-old man presents with hemoptysis, diffuse muscle pain, and shortness of breath. He has had these symptoms before but did not seek treatment. His past medical history is not known as he is not typically followed by a doctor and is homeless. His temperature is 99.0°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 89/min, respirations are 22/min, and oxygen saturation is 90% on room air. Physical examination is notable for crackles noted in the bases of the lungs bilaterally. Labs values are ordered as seen below.\n\nSerum:\nNa+: 140 mEq/L\nCl-: 103 mEq/L\nK+: 5.8 mEq/L\nHCO3-: 21 mEq/L\nBUN: 33 mg/dL\nGlucose: 129 mg/dL\nCreatinine: 2.6 mg/dL\n\nUrine:\nColor: Amber\nProtein: Positive\nBlood: Positive\n\nWhich of the following is the most appropriate treatment for this patient?", "answer": "Methylprednisolone, plasmapheresis, and cyclophosphamide", "options": {"A": "Methylprednisolone", "B": "Methylprednisolone and cyclophosphamide", "C": "Methylprednisolone, plasmapheresis, and cyclophosphamide", "D": "Plasmapheresis and cyclophosphamide"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "hemoptysis", "diffuse muscle", "shortness of breath", "symptoms", "not", "treatment", "past medical history", "not known", "not", "followed by", "doctor", "homeless", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "90", "room air", "Physical examination", "notable", "crackles noted", "the bases of", "lungs", "Labs values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "mEq/L K", "5.8 mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "2.6 mg/dL", "Urine", "Color", "Amber Protein", "Positive Blood", "Positive", "following", "most appropriate", "patient"]}
{"question": "A 39-year-old woman presents with headaches, constipation, increased thirst, and increased urinary frequency. Her blood pressure is 160/100 mm Hg and pulse is 67/min. Blood tests reveal high blood glucose and low potassium level. Abdominal CT scan shows a well-circumscribed homogeneous mass in the left adrenal gland. The hormone excess responsible for her symptoms uses which of the following pathways to exert its action?", "answer": "Intracellular receptors", "options": {"A": "Intracellular receptors", "B": "cAMP pathway", "C": "cGMP pathway", "D": "JAK/STAT pathway"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "headaches", "constipation", "increased thirst", "increased urinary frequency", "blood pressure", "100 mm Hg", "pulse", "67 min", "Blood tests reveal high blood glucose", "low potassium level", "Abdominal CT shows", "well circumscribed homogeneous mass", "left", "hormone excess responsible", "symptoms uses", "following pathways to exert", "action"]}
{"question": "A 55-year-old man presents to the emergency department with a headache. He states that this is the worst headache he has ever had and that his symptoms have not been improving. The patient complains of pain in his jaw that is worse when he chews. He has a past medical history of insomnia and is currently taking alprazolam. His temperature is 98.2°F (36.8°C), blood pressure is 157/98 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam is notable for tenderness over the patient's scalp, jaw, and temporal area. Which of the following is the best next step in management?", "answer": "IV steroids", "options": {"A": "CT head", "B": "Ibuprofen", "C": "IV steroids", "D": "Lumbar puncture"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["55 year old man presents", "emergency department", "headache", "states", "worst headache", "symptoms", "not", "improving", "patient", "pain", "jaw", "worse", "chews", "past medical insomnia", "currently taking alprazolam", "temperature", "98", "36", "blood pressure", "98 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "tenderness", "patient's scalp", "jaw", "temporal area", "following", "best next step", "management"]}
{"question": "A 34-year-old man with acute lymphocytic leukemia presents for follow-up in the oncology clinic after his second cycle of chemotherapy. In addition to intermittent nausea, he has mild weakness, tingling, and numbness in his left hand. With his affected hand, he is able to grip, but occasionally drops small objects. His oncologist tells him that one of his chemotherapy agents likely caused his neuropathy given its strong association with neurotoxicity. He was recently treated with cyclophosphamide, vincristine, doxorubicin, dexamethasone, and dasatinib. The culprit medication works by which of the following mechanisms of action?", "answer": "Blocks microtubule formation", "options": {"A": "Covalently X-links DNA", "B": "Blocks microtubule formation", "C": "Intercalates between DNA", "D": "Modifies DNA transcription and protein synthesis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "acute lymphocytic leukemia presents", "follow-up", "oncology clinic", "second", "chemotherapy", "intermittent nausea", "mild weakness", "tingling", "numbness", "left", "affected hand", "able to grip", "occasionally drops small objects", "oncologist", "one", "chemotherapy agents likely caused", "neuropathy given", "strong association", "neurotoxicity", "recently treated with cyclophosphamide", "vincristine", "doxorubicin", "dexamethasone", "dasatinib", "medication works", "of", "following mechanisms", "action"]}
{"question": "A 1-day-old infant is in the neonatal intensive care unit due to respiratory failure from pulmonary hypoplasia. The mother is a healthy 32-year-old woman who did not have regular prenatal exams. On physical examination, you notice low-set ears and retrognathia with abnormal extremity development. Which of the following abnormalities is associated with the most likely cause of this patient's symptoms?", "answer": "Posterior urethral valves", "options": {"A": "Hepatosplenomegaly", "B": "Posterior urethral valves", "C": "Rocker bottom feet", "D": "Duodenal atresia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["day old infant", "neonatal intensive care unit due to respiratory failure", "pulmonary hypoplasia", "mother", "healthy", "year old woman", "not", "regular prenatal exams", "physical examination", "low-set ears", "retrognathia", "abnormal extremity development", "following abnormalities", "associated with", "likely cause", "patient's symptoms"]}
{"question": "A 47-year-old woman with metastatic breast cancer who is undergoing chemotherapy comes to the physician for a follow-up exam. She reports extreme fatigue since beginning her chemotherapy regimen. Her pulse is 98/min, respirations are 16/min, and blood pressure is 132/84 mm Hg. Her hemoglobin is 10.4 g/dL, leukocyte count is 800/mm3 with 5% monocytes, and platelet count is 50,000/mm3. The patient is started on a new medication. One week later, serum studies show a hemoglobin of 10.6 g/dL, a leukocyte count of 2,000/mm3 with 2% monocytes, and a platelet count of 56,000/mm3. Which of the following drugs is the most likely cause of these findings?", "answer": "Filgrastim", "options": {"A": "Aldesleukin", "B": "Interferon beta", "C": "Filgrastim", "D": "Romiplostim"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "metastatic", "chemotherapy", "physician", "follow-up exam", "reports extreme fatigue", "beginning", "chemotherapy regimen", "pulse", "98 min", "respirations", "min", "blood pressure", "84 mm Hg", "hemoglobin", "10.4 g/dL", "leukocyte count", "800 mm3", "monocytes", "platelet count", "50", "mm3", "patient", "started", "new medication", "One week later", "serum studies show a hemoglobin", "10.6 dL", "leukocyte count", "mm3", "2", "monocytes", "platelet count", "mm3", "following drugs", "most likely cause", "findings"]}
{"question": "A male newborn born at 27 weeks' gestation is evaluated for rapid breathing and hypoxia shortly after birth. His mother had no prenatal care. Cardiopulmonary examination shows normal heart sounds, intercostal retractions, and nasal flaring. An x-ray of the chest shows low lung volumes, air bronchograms, and diffuse ground-glass opacities. He is started on nasal continuous positive airway pressure. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Hyaline membranes lining the alveoli on lung biopsy", "options": {"A": "Bilateral pleural effusions on lung ultrasound", "B": "Corkscrew-shaped organisms on umbilical cord culture", "C": "Hyaline membranes lining the alveoli on lung biopsy", "D": "Meconium-stained fluid on deep suctioning"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["male newborn born", "27 weeks", "gestation", "evaluated", "rapid breathing", "hypoxia", "birth", "mother", "prenatal care", "Cardiopulmonary examination shows normal heart sounds", "intercostal retractions", "nasal flaring", "x-ray of", "chest shows low lung volumes", "air bronchograms", "diffuse ground-glass opacities", "started", "nasal continuous positive airway pressure", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "A 38-year-old woman is brought to the emergency department because of three 1-hour episodes of severe, sharp, penetrating abdominal pain in the right upper quadrant. During these episodes, she has had nausea and vomiting. She has no diarrhea, dysuria, or hematuria and is asymptomatic between episodes. She has hypertension and hyperlipidemia. Seven years ago, she underwent resection of the terminal ileum because of severe Crohn's disease. She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32 kg/m2. Her temperature is 36.9°C (98.5°F), pulse is 80/min, and blood pressure is 130/95 mm Hg. There is mild scleral icterus. Cardiopulmonary examination shows no abnormalities. The abdomen is soft, and there is tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. The stool is brown, and test for occult blood is negative. Laboratory studies show:\nHemoglobin 12.5 g/dL\nLeukocyte count 9,500 mm3\nPlatelet count 170,000 mm3\nSerum\nTotal bilirubin 4.1 mg/dL\nAlkaline phosphatase 348 U/L\nAST 187 U/L\nALT 260 U/L\nAbdominal ultrasonography shows a normal liver, a common bile duct caliber of 10 mm (normal < 6 mm) and a gallbladder with multiple gallstones and no wall thickening or pericholecystic fluid. Which of the following is the most likely cause of these findings?\"", "answer": "Choledocholithiasis", "options": {"A": "Acute hepatitis A", "B": "Choledocholithiasis", "C": "Cholecystitis", "D": "Pancreatitis\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "three 1 hour episodes", "severe", "sharp", "penetrating abdominal pain", "right upper quadrant", "episodes", "nausea", "vomiting", "diarrhea", "dysuria", "hematuria", "asymptomatic", "episodes", "hypertension", "hyperlipidemia", "Seven years", "resection of", "terminal ileum", "severe Crohn", "isease.", "  t   ", "all ", "g ", "MI ", "g/m2.", "emperature ", "6.", "8.", "ulse ", "0/ in,", "lood pressure ", "5  m Hg.", "ild  cleral icterus.", "ardiopulmonary  xamination  hows ", "bnormalities.", "bdomen ", "oft,", "enderness ", "alpation ", "ight upper quadrant ", "uarding ", "owel sounds ", "ormal.", "tool ", "rown,", "est ", "ccult blood ", "egative.", "aboratory studies  how:", "emoglobin  2.5 ", "eukocyte count ", "m3  latelet count ", "erum ", "lkaline phosphatase  48 ", " ", "bdominal  ltrasonography  hows ", "ormal liver,", "ommon bile duct  aliber ", "0  m ", "ormal ", " mm)", "allbladder ", "ultiple  allstones ", "all  hickening ", "luid.", "ollowing ", "ost  ikely  ause ", "indings?"]}
{"question": "A 31-year-old G1-P0 woman at 28-weeks gestation presents with shortness of breath and nonspecific right-sided chest pain that is worse with inspiration. She works as a graduate student at the local university, and she informs you that she recently returned to the west coast from a trip to New York for an Economics conference. Her medical history is positive only for frequent bouts of sinusitis. She currently denies any smoking, drinks a glass of red wine/day, and she denies any past illicit drug use. The vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 87/min, and respiratory rate 23/min. Her physical examination shows decreased air movement throughout the right lung but otherwise clear lungs on auscultation, grade 2/6 holosystolic murmur, and a gravid uterus without acute findings. On physical examination, she is afebrile, tachycardic to 121/min, normotensive, and demonstrates an O2 saturation of 92%. Which of the following is the best next step in the evaluation of the most likely diagnosis for this patient?", "answer": "V/Q scan", "options": {"A": "ECG", "B": "Chest radiography", "C": "V/Q scan", "D": "CT pulmonary angiogram"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["31 year old G1 P0 woman", "weeks presents", "shortness of breath", "nonspecific right-sided", "worse", "inspiration", "works", "graduate student", "local university", "informs", "recently returned", "west", "trip", "New York", "Economics conference", "medical history", "positive only", "frequent bouts", "sinusitis", "currently denies", "smoking", "drinks", "glass", "red wine day", "denies", "past illicit drug use", "vital signs include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate 87 min", "respiratory rate 23 min", "physical examination shows decreased air movement", "right lung", "clear lungs", "auscultation", "grade", "6 holosystolic murmur", "gravid uterus", "acute findings", "physical examination", "afebrile", "tachycardic", "min", "normotensive", "demonstrates", "O2 saturation", "following", "best next step", "evaluation", "likely diagnosis", "patient"]}
{"question": "An otherwise healthy 29-year-old man presents to his family physician with a slowly growing left neck mass for the past 5 weeks. He denies fever or recent upper respiratory tract infections. His temperature is 37.1°C (98.7°F), the blood pressure is 115/72 mm Hg, and the pulse are 82/min. On examination, a 4-cm (1.5 in), firm, non-tender mass is detected on the mid-left neck. Excisional biopsy of the mass reveals Hodgkin’s cells. The patient is referred to the oncology department and chemotherapy is started. After the first cycle of chemotherapy, the patient notices that his urine becomes red. The urine tests are positive for blood on further analysis. Which of the following is the most likely cause of this patient condition?", "answer": "Cyclophosphamide", "options": {"A": "Bleomycin", "B": "Cyclophosphamide", "C": "Doxorubicin", "D": "Etoposide"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["healthy 29 year old man presents", "family physician", "slowly", "left neck mass", "past", "weeks", "denies fever", "recent upper respiratory tract infections", "temperature", "98", "blood pressure", "72 mm Hg", "pulse", "min", "examination", "4", "1.5", "firm", "non-tender mass", "detected", "left neck", "Excisional biopsy of", "mass reveals Hodgkins cells", "patient", "referred", "oncology department", "chemotherapy", "started", "first cycle", "chemotherapy", "patient", "urine", "red", "urine tests", "positive", "blood", "further analysis", "following", "most likely cause", "patient condition"]}
{"question": "An 18-year-old woman is brought to the emergency department because of lightheadedness and a feeling of dizziness. She has had nausea, occasional episodes of vomiting, myalgia, and a generalized rash for the past week. She also reports feeling lethargic. She has no shortness of breath. There is no family history of serious illness. She appears ill. Her temperature is 39.1°C (102.3°F), pulse is 118/min, and blood pressure is 94/60 mm Hg. Cardiac examination shows no abnormalities. There is a widespread erythematous rash on the trunk and extremities with skin peeling on the palms and soles. Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 19,300/mm3\nPlatelet count 98,000/mm3\nSerum\nUrea nitrogen 47 mg/dL\nGlucose 88 mg/dL\nCreatinine 1.8 mg/dL\nTotal bilirubin 2.1 mg/dL\nAST 190 U/L\nALT 175 U/L\nUrinalysis shows no abnormalities. Further evaluation of this patient's history is most likely to reveal which of the following?\"", "answer": "Currently menstruating", "options": {"A": "Recent hiking trip", "B": "Intravenous heroin abuse", "C": "Exposure to a patient with mengingococcemia", "D": "Currently menstruating"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "lightheadedness", "feeling", "dizziness", "nausea", "occasional episodes of vomiting", "myalgia", "generalized rash", "past week", "reports feeling lethargic", "shortness of breath", "family history", "serious illness", "appears ill", "temperature", "pulse", "min", "blood pressure", "60 mm Hg", "Cardiac examination shows", "abnormalities", "widespread erythematous", "trunk", "extremities", "skin", "palms", "soles", "Laboratory studies show", "Hemoglobin 13", "Leukocyte 19", "Platelet count", "nitrogen", "L", "Urinalysis shows", "abnormalities", "Further evaluation", "patient", "istory ", "ost likely  o  eveal ", "ollowing?"]}
{"question": "A 62-year-old man presents to the emergency department for evaluation of a low-grade fever, worsening fatigue, and mild intermittent abdominal pain that is not affected by eating. He reports that over the last 6 months he slept a lot more than usual and lost 14.9 kg (33 lbs) without trying to lose weight. He also complains of chest pain and shortness of breath that is worse when he is working and in the yard. There is no significant family history. His long-standing male partner passed away 2 years ago in a fatal car accident. His blood pressure is 145/75 mm Hg, the pulse is 90/min, the respiratory rate is 23/min, and the temperature is 38°C (100.5°F). On physical examination, he has pale mucous membranes, conjunctival hemorrhages, and petechiae on his lower extremities. There is a new-onset high-pitched blowing diastolic murmur best heard over the right upper sternal border. His head bobs with each heartbeat. There are small, painless, red macules on both palms. His spleen is palpable 3 cm below the left costal margin. His laboratory results are shown below.\nHemoglobin 8.4 g/dL\nMean corpuscular volume 72 µm3\nPlatelet count 400,000/mm3\nLeukocytes 6,000/mm3\nSerum ferritin 8 ng/mL\nSerum iron 27 µg/dL\nTotal iron-binding capacity 450 µg/dL\nColonoscopy with biopsy is later performed showing a neoplastic growth in the descending colon. Which of the following is the most likely explanation for his cardiac findings?", "answer": "Group D streptococci", "options": {"A": "Treponema pallidum", "B": "Malignant colonic neoplasm", "C": "Collagen vascular disease", "D": "Group D streptococci"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old man presents", "emergency department", "evaluation", "low-grade fever", "worsening fatigue", "mild intermittent abdominal pain", "not affected", "eating", "reports", "last", "months", "slept", "lot", "usual", "lost", "kg", "lbs", "to", "weight", "of chest pain", "shortness of breath", "worse", "working", "yard", "significant family history", "long standing male partner passed", "years", "fatal car accident", "blood pressure", "75 mm Hg", "pulse", "90 min", "respiratory rate", "23 min", "temperature", "100", "physical examination", "pale mucous membranes", "conjunctival hemorrhages", "petechiae", "lower extremities", "new-onset high-pitched blowing diastolic murmur best heard", "right upper sternal border", "head bobs", "heartbeat", "small", "painless", "red macules", "palms", "spleen", "palpable 3 cm", "left costal margin", "laboratory results", "shown", "Hemoglobin 8.4 g dL Mean corpuscular volume 72", "Platelet count 400", "mm3 Leukocytes", "Serum", "ng/mL", "iron 27", "dL Total", "450", "Colonoscopy", "biopsy", "later performed showing", "neoplastic growth", "descending colon", "following", "most likely explanation", "cardiac findings"]}
{"question": "A 33-year-old woman presents to the clinic for follow-up of her AIDS treatment with highly active anti-retroviral therapy (HAART). She is in good spirits and has been fully compliant with her medications and clinic visits. Other medications include prophylactic co-trimoxazole. Recent blood studies show the following:\nHemoglobin (Hb%)  11 g/dL\nMean corpuscular volume (MCV)  80 fl\nReticulocyte count 0.5%\nErythrocyte count 2 x 106/mm3\nLeucocyte count 700/mm3\nNeutrophils 40%\nPlatelet count 20,000/mm3\nAssays also show a decreased viral DNA and mRNA burden, as well as a significantly diminished viral load. To avoid modifying the effective anti-retroviral therapy, she is started on a ‘blood improving’ medication. Thirty minutes after the first dose, the patient develops difficulty breathing, severe muscle pain, and vomiting. Her pulse rate is 120/min and the blood pressure is 80/50 mm Hg. Which of the following medications was most likely administered to the patient?", "answer": "Sargramostim", "options": {"A": "Interleukin 3", "B": "Platelet-derived growth factor", "C": "Sargramostim", "D": "Thrombopoietin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "clinic", "follow-up", "AIDS treatment", "highly active anti-retroviral therapy", "good spirits", "compliant", "medications", "clinic visits", "medications include prophylactic co-trimoxazole", "Recent blood studies show", "following", "Hemoglobin", "Hb", "g dL Mean corpuscular volume", "80 fl Reticulocyte count", "Erythrocyte", "2", "mm3 Leucocyte count 700", "40", "Platelet count 20", "Assays", "show", "decreased viral DNA", "mRNA burden", "diminished viral load", "To", "modifying", "effective anti-retroviral therapy", "started", "blood improving medication", "Thirty minutes", "first dose", "patient", "difficulty breathing", "severe muscle", "vomiting", "pulse rate", "min", "blood pressure", "80 50 mm Hg", "following medications", "most likely administered", "patient"]}
{"question": "A 77-year-old woman is brought to the emergency department by her husband because of increasing confusion and unusual behavior for 2 days. She has been mumbling to herself and wandering around the neighborhood. These symptoms are worse in the evenings and she has hardly slept at night. She has not been eating or drinking much for the past 6 days. She has hypertension treated with hydrochlorothiazide. She was diagnosed with breast cancer 12 years ago and was treated with left-sided mastectomy. The patient is oriented to person but not to place or time. Her temperature is 37.1°C (98.8°F), pulse is 78/min, respirations are 18/min, and blood pressure is 122/80 mm Hg. Physical examination shows a supple neck. Neurologic examination shows psychomotor agitation. Attention and concentration are impaired; she makes multiple errors while performing the serial sevens test. Her speech is disorganized. Her fingerstick blood glucose concentration is 122 mg/dL. Which of the following is the most appropriate next step in management?", "answer": "Check serum electrolytes", "options": {"A": "Check serum TSH level", "B": "Check serum electrolytes", "C": "Perform CT scan of the head", "D": "Perform chest x-ray"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "brought", "emergency department", "husband", "increasing confusion", "unusual behavior", "2 days", "wandering", "neighborhood", "symptoms", "worse", "evenings", "slept", "night", "not", "eating", "drinking", "past 6 days", "hypertension treated with hydrochlorothiazide", "diagnosed", "breast cancer", "years", "treated with left-sided mastectomy", "patient", "oriented to person", "not to place", "time", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "80 mm Hg", "Physical examination shows", "supple neck", "Neurologic shows psychomotor agitation", "Attention", "concentration", "impaired", "makes multiple errors", "performing", "serial sevens test", "speech", "fingerstick blood glucose concentration", "mg/dL", "following", "most appropriate next step", "management"]}
{"question": "A 39-year-old woman comes to the physician because of fever, generalized fatigue, and chills for 1 week. She has been having dull right-side abdominal pain during this period. She has nausea. She has no history of travel outside the United States. She has type 1 diabetes mellitus. Current medications include insulin and an oral contraceptive. She appears ill. Her temperature is 40°C (104°F), pulse is 118/min, and blood pressure is 106/70 mm Hg. On examination, the liver is palpated 2–3 cm below the right costal margin and is tender. There are decreased breath sounds over the right lung base. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 14.1 g/dL\nLeukocyte count 17,100/mm3\nSegmented neutrophils 74%\nEosinophils 1%\nLymphocytes 20%\nMonocytes 5%\nSerum\nGlucose 79 mg/dL\nCreatinine 1.1 mg/dL\nTotal bilirubin 0.9 mg/dL\nAlkaline phosphatase 180 U/L\nAST 69 U/L\nALT 100 U/L\nA right upper quadrant ultrasound is shown. Which of the following is the most appropriate next step in management?\"", "answer": "Perform percutaneous drainage\n\"", "options": {"A": "Discontinue the oral contraceptive", "B": "Obtain hepatoiminodiacetic acid scan", "C": "Perform endoscopic retrograde cholangiopancreatography", "D": "Perform percutaneous drainage\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "fever", "generalized fatigue", "chills", "1 week", "dull right-side abdominal pain", "period", "nausea", "history of travel outside", "United States", "type 1 diabetes mellitus", "Current medications include insulin", "oral contraceptive", "appears ill", "temperature", "pulse", "min", "blood pressure", "70 mm Hg", "examination", "liver", "palpated 23 cm", "right costal margin", "tender", "decreased breath sounds", "right lung base", "examination shows", "abnormalities", "Laboratory studies show", "Hemoglobin", "dL Leukocyte count", "mm3 Segmented", "Eosinophils", "Lymphocytes 20", "Serum", "mg dL Creatinine", "0.9", "L", "69", "right upper quadrant ultrasound", "shown", "following", "most appropriate next step", "management"]}
{"question": "A 57-year-old man presents to his primary care physician for follow-up of his diabetes. He was diagnosed with type 2 diabetes 3 months ago and has been started on metformin and lifestyle modifications. The patient does not have any current complaints except for occasional numbness in both hands and feet. His HbA1C is 8.5% and serum glucose is 240 mg/dL. Which of the following is the best next step in this patient’s condition?", "answer": "Add a sulfonylurea", "options": {"A": "Start basal-bolus insulin", "B": "Continue metformin monotherapy", "C": "Add a sulfonylurea", "D": "Add a thiazolidinedione"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["57 year old man presents", "primary care physician", "follow-up", "diabetes", "diagnosed", "type months", "started", "metformin", "lifestyle modifications", "patient", "not", "current complaints", "occasional numbness", "hands", "feet", "8.5", "serum glucose", "mg/dL", "following", "best next step", "patients condition"]}
{"question": "A 42-year-old chronic alcoholic man was admitted to the hospital for inappropriate behavior and disturbed memory. He presents with severe retrograde memory loss, confusion, and confabulation. Neurologic examination showed horizontal nystagmus. He also has bilateral pretibial pitting edema and perioral erythema. CT studies of the brain were normal. The duty physician suspects the patient may be vitamin deficient. Which of the following reactions does the deficient vitamin mediate?", "answer": "Alpha-Ketoglutarate + NAD+ + CoA <=> Succinyl-CoA + CO2 + NADH", "options": {"A": "Alpha-Ketoglutarate + NAD+ + CoA <=> Succinyl-CoA + CO2 + NADH", "B": "Succinate + FAD (enzyme bound) <=> Fumarate + FADH2", "C": "Isocitrate + NAD+ <=> Alpha-Ketoglutarate + CO2 + NADH", "D": "Succinyl-CoA + Pi + GDP <=> Succinate + GTP + CoA"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old chronic alcoholic man", "admitted", "hospital", "inappropriate behavior", "memory", "presents", "severe retrograde memory loss", "confusion", "confabulation", "Neurologic examination showed horizontal nystagmus", "bilateral", "pitting edema", "perioral erythema", "CT studies", "brain", "normal", "physician suspects", "patient", "vitamin deficient", "following reactions", "deficient vitamin mediate"]}
{"question": "A 28-year-old woman, gravida 2, para 1, at 40 weeks gestation is brought to the emergency department by her husband. She is in active labor and has lost a lot of blood in the past 2 hours, but appears alert and cooperative. At the hospital, her blood pressure is 88/65 mm Hg, the pulse is 110/min, and the respirations are 23/min. Neither the hospital nor the emergency department is equipped for high-risk pregnancies. The patient and her husband request a transfer to a more capable center. They are informed of the hospital’s obligations under the Emergency Medical Treatment and Labor Act and the risks of transfer. They insist to be transferred. Which of the following is the most appropriate next step in management?", "answer": "Treat and transfer the patient after she makes a written request", "options": {"A": "Decline admission and refer the patient to the closest capable emergency department", "B": "Disregard patient’s request and treat until delivery is complete", "C": "Treat and transfer the patient after she makes a written request", "D": "Transfer the patient only if the medical benefits of transfer outweigh the risks"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "40 weeks gestation", "brought", "emergency department", "husband", "in active labor", "lost", "lot", "blood", "past", "hours", "appears alert", "cooperative", "hospital", "blood pressure", "88 65 mm Hg", "pulse", "min", "respirations", "23 min", "hospital", "emergency department", "high-risk pregnancies", "patient", "husband request", "transfer", "capable center", "informed", "hospitals", "Emergency Medical", "Labor Act", "risks", "transfer", "to", "transferred", "following", "most appropriate next step", "management"]}
{"question": "A 7-year-old boy is brought to your office with complaints of wheezing and dyspnea. Laboratory work reveals eosinophilia and positive skin tests for allergens. Which of the following types of drugs would be an effective treatment in this patient?", "answer": "Muscarinic antagonist", "options": {"A": "Beta-2 antagonist", "B": "Histone deacetylase inhibitor", "C": "Muscarinic antagonist", "D": "Anticoagulant"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "office", "complaints", "wheezing", "dyspnea", "Laboratory work reveals eosinophilia", "positive skin tests for allergens", "of", "following types", "drugs", "effective", "patient"]}
{"question": "A 16-year-old healthy female presents to her pediatrician concerned that she has not had a menstrual period. She has no past medical history and takes no medications. She plays volleyball and gets good grades in school. Her BMI is 22 kg/m2. Physical examination reveals normal female external genitalia and pubic hair along the mons pubis and superomedial thighs. Her breasts appear normal. Transabdominal ultrasound reveals an absent uterus. Serum testosterone levels is within the normal range for females. What is the most likely cause of this patient’s condition?", "answer": "Failure of paramesonephric duct development", "options": {"A": "Pituitary tumor", "B": "Absence of second X chromosome", "C": "Androgen receptor mutation", "D": "Failure of paramesonephric duct development"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old healthy female presents", "pediatrician concerned", "not", "menstrual period", "past medical history", "takes", "medications", "plays volleyball", "gets good grades in school", "BMI", "kg/m2", "Physical examination reveals normal female external genitalia", "pubic hair", "mons pubis", "superomedial thighs", "breasts appear normal", "Transabdominal ultrasound reveals", "absent uterus", "Serum testosterone levels", "normal range", "females", "most likely cause", "patients condition"]}
{"question": "A 61-year-old nulliparous woman comes to the physician for a follow-up examination. Her last Pap smear 3 years ago showed atypical squamous cells of undetermined significance. HPV testing was negative at that time. On questioning, she has had fatigue and an increase in abdominal girth despite a 5-kg (11.0-lb) weight loss over the past 6 months. She has gastroesophageal reflux disease and Hashimoto's thyroiditis. Menarche was at the age of 10 years and her last menstrual period was 2 years ago. Current medications include omeprazole and levothyroxine. Abdominal examination shows shifting dullness. There is tenderness to palpation of the right lower quadrant but no guarding or rebound. Bimanual palpation shows a small uterus and a right adnexal mass. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Elevated serum CA-125 level", "options": {"A": "Elevated serum CA-125 level", "B": "Elevated serum beta-hCG level", "C": "Prolonged prothrombin time", "D": "Cervical dysplasia on Pap smear"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["61 year old nulliparous woman", "physician", "follow-up examination", "last Pap smear", "years", "showed atypical squamous cells of undetermined significance", "HPV testing", "negative", "time", "questioning", "fatigue", "increase", "abdominal", "5 kg", "0", "weight loss", "past 6 months", "gastroesophageal reflux disease", "Hashimoto's thyroiditis", "Menarche", "age", "10", "last menstrual period", "2 years", "Current medications include omeprazole", "levothyroxine", "Abdominal examination shows shifting dullness", "tenderness", "palpation", "right lower quadrant", "guarding", "Bimanual palpation shows", "small uterus", "right adnexal mass", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "An unresponsive 92-year-old man is brought to the emergency department by ambulance and is quickly followed by his grand-daughter. Approx. 1 month ago, he had a radical prostatectomy, pelvic radiation, and several rounds of chemotherapy for aggressive prostate cancer in Nicaragua and was discharged from the hospital with a suprapelvic catheter and a plan for more chemotherapy. He was coming to the United States to spend time with some extended family. According to the grand-daughter his mental status was altered upon arrival and his health began to decline. She is not aware of his past medical status or medications. At the hospital, his blood pressure is 98/60 mm Hg, the pulse id 110/min, the respiratory rate is 21/min, and the temperature is 35.6°C (96.1°F). On physical exam, the patient appears cachectic, drowsy, and only responds to questions by nodding his head. His heart rate is tachycardic with a regular rhythm and his lungs are clear to auscultation bilaterally. The cystotomy incision for his suprapelvic catheter is red and swollen. The patient admitted to the hospital and stabilized and started on broad-spectrum antibiotics. The catheter tube produces no urine over 24 hours and only thick green-white puss can be expressed. The treatment team concludes this patient has urinary tract obstruction. What is the best method to evaluate urinary tract obstruction in this patient?", "answer": "Ultrasound", "options": {"A": "Renal biopsy", "B": "Ultrasound", "C": "Abdominal-pelvic CT scan", "D": "Blood analysis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["unresponsive", "year old man", "brought", "emergency department", "ambulance", "followed by", "grand-daughter", "month", "radical prostatectomy", "pelvic radiation", "several rounds", "chemotherapy", "aggressive prostate", "Nicaragua", "discharged from", "hospital", "catheter", "plan", "chemotherapy", "United States to spend time", "extended family", "grand-daughter", "mental status", "altered", "arrival", "health began to", "not aware", "past medical status", "medications", "hospital", "blood pressure", "98 60 mm Hg", "pulse id", "min", "respiratory rate", "min", "temperature", "35", "96", "physical exam", "patient appears cachectic", "drowsy", "only", "questions", "nodding", "head", "heart rate", "tachycardic", "regular rhythm", "lungs", "clear", "auscultation", "cystotomy incision", "catheter", "red", "swollen", "patient admitted", "hospital", "stabilized", "started", "broad spectrum antibiotics", "catheter tube", "urine", "24 hours", "only thick green white", "treatment team concludes", "patient", "urinary tract obstruction", "best method to evaluate urinary tract obstruction", "patient"]}
{"question": "A 51-year-old man presents to his primary care provider for intermittent shaking of his hands. He reports that for the last several years he has noticed this \"shaking\" when he brushes his teeth and prepares a cup of coffee in the morning. The shaking then gradually improves over the course of the day. His past medical history is otherwise notable for hypertension and hyperlipidemia. His only home medication is pravastatin. The patient smokes half a pack per day of cigarettes and drinks 2-3 beers throughout the day. His family history is significant for Parkinson disease in his father. On physical exam, his blood pressure is 159/84, pulse is 74/min, and respirations are 12/min. He has a high frequency bilateral hand tremor elicited on finger-to-nose testing. His neurological exam is otherwise unremarkable. This patient should be started on which of the following medications?", "answer": "Propranolol", "options": {"A": "Alprazolam", "B": "Primidone", "C": "Propranolol", "D": "Trihexyphenidyl"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider", "intermittent shaking of", "hands", "reports", "last", "years", "shaking", "brushes", "teeth", "prepares", "cup", "coffee", "morning", "shaking then", "improves", "course", "day", "past medical history", "notable", "hypertension", "hyperlipidemia", "only home medication", "pravastatin", "patient smokes half", "pack", "day", "cigarettes", "drinks 2 beers", "day", "family history", "significant", "Parkinson disease", "father", "physical exam", "blood pressure", "84", "pulse", "74 min", "respirations", "min", "high frequency bilateral hand tremor elicited", "finger", "nose testing", "neurological exam", "unremarkable", "patient", "started", "following medications"]}
{"question": "A pediatrician notices that 9 of her patients this year have developed paralysis after a flu-like illness. They range in age from 7 to 11, and most of them had no abnormal activities prior to developing the paralysis. These patients concern her because she has not seen this type of paralytic illness in over 20 years of practice. Based on this experience, she decides to write up the initial presentation and clinical course of these patients and publish them in a journal. Which of the following is most likely true about this study?", "answer": "Hypothesis testing cannot be performed", "options": {"A": "Different interventions with 2 or more variables can be studied", "B": "Hypothesis testing cannot be performed", "C": "It should be reported in terms of odds ratio", "D": "Participants act as their own controls"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["pediatrician", "patients", "year", "paralysis", "flu-like illness", "range", "age", "most", "abnormal activities prior to", "paralysis", "patients concern", "not seen", "type", "illness", "over 20 years", "practice", "Based", "experience", "write", "initial presentation", "clinical course", "patients", "publish", "journal", "following", "most likely true", "study"]}
{"question": "A 3-year-old boy is brought to the emergency department by ambulance after a motor vehicle accident. He is unconscious upon arrival and is found to have severe internal bleeding due to trauma. He is taken for emergency surgery and severely damaged tissues are removed. After surgery, the boy is taken into the PICU for recovery. Over the subsequent week, serial labs are drawn showing target cells, thrombocytosis, and leukocytosis. He is started on a prophylactic regimen that is continued upon discharge. Which of the following is consistent with the mechanism of action of the drug that was most likely prescribed in this case?", "answer": "Cell wall cross-linking inhibitor", "options": {"A": "30S ribosome inhibitor", "B": "50S ribosome inhibitor", "C": "Cell wall cross-linking inhibitor", "D": "DNA gyrase inhibitor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "emergency department", "ambulance", "motor vehicle accident", "unconscious", "arrival", "found to", "severe internal due to trauma", "taken", "emergency surgery", "severely damaged tissues", "removed", "surgery", "boy", "taken", "PICU", "recovery", "subsequent week", "serial labs", "drawn showing target cells", "thrombocytosis", "leukocytosis", "started", "prophylactic regimen", "continued", "discharge", "following", "consistent with", "mechanism of action", "drug", "most likely prescribed", "case"]}
{"question": "A 25-year-old man presents to his primary care provider complaining of several weeks of intense itching, particularly localized around his anus. Of note, the patient denies any recent travel, sexual contacts, fever, dysuria, or diarrhea. His temperature is 98.1°F (36.7°C), blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 12/min. On exam, the patient demonstrates severe excoriations in his perianal region with slight erythema over the areas that are torn. He does not have any other dermatologic findings. The scotch tape test is positive. The patient has a previous documented allergy to albendazole. Which of the following is an alternative medication that can be used?", "answer": "Pyrantel pamoate", "options": {"A": "Amphotericin B", "B": "Ivermectin", "C": "Praziquantel", "D": "Pyrantel pamoate"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care provider complaining of", "weeks", "intense itching", "localized", "anus", "note", "patient denies", "recent travel", "sexual contacts", "fever", "dysuria", "diarrhea", "temperature", "98", "36", "blood pressure", "70 mmHg", "pulse", "65 min", "respirations", "min", "exam", "patient demonstrates severe excoriations", "perianal", "slight erythema", "areas", "torn", "not", "dermatologic findings", "scotch tape test", "positive", "patient", "previous documented allergy", "albendazole", "following", "alternative medication", "used"]}
{"question": "A 21-year-old female presents to the office after a health screening in which she was found to have high blood pressure. At the office, the blood pressure is 168/114 mm Hg. You have seen the patient in the past for amenorrhea and infertility issues, but she denies taking any medication at this time. On examination, the patient is short and normal weight but has a webbed neck. Which of the following is the most likely cause of the elevated blood pressure?", "answer": "Central fusion of the inferior poles of the kidneys ", "options": {"A": "Central fusion of the inferior poles of the kidneys ", "B": "Genetic predisposition to essential hypertension", "C": "Neuroendocrine tumor of the adrenal gland", "D": "Oral contraceptive use"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["21-year-old female presents", "office", "health screening", "found to", "high blood pressure", "office", "blood pressure", "mm Hg", "seen", "patient", "past", "amenorrhea", "infertility issues", "denies taking", "medication", "time", "examination", "patient", "short", "normal weight", "webbed neck", "following", "most likely cause", "elevated blood pressure"]}
{"question": "A 25-year-old African American man presents to his primary care provider for routine blood work. He is a well-known case of sickle cell disease treated with hydroxyurea and tramadol as needed for pain. He does not smoke or drink alcohol. The patient asks if his disease can adversely affect his kidneys because his friend was recently diagnosed with end-stage renal failure. Which of the following is a renal complication of sickle cell disease?", "answer": "Impaired urine concentration ability", "options": {"A": "Membranous glomerulonephritis", "B": "Proximal renal tubular acidosis", "C": "Impaired urine diluting ability", "D": "Impaired urine concentration ability"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old African American man presents", "primary care provider", "routine blood work", "well known case", "sickle cell disease treated with hydroxyurea", "tramadol as needed", "pain", "not smoke", "drink alcohol", "patient", "his disease", "affect", "kidneys", "friend", "recently diagnosed", "end-stage renal failure", "following", "renal complication of sickle cell disease"]}
{"question": "A gunshot victim is brought to the Emergency Department and appears to be in shock. You note a penetrating wound at the level of L3. Assuming the bullet remained at this level, which vascular structure might have been injured?", "answer": "Inferior vena cava", "options": {"A": "Inferior vena cava", "B": "Internal iliac vein", "C": "Renal artery", "D": "Portal vein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["gunshot victim", "brought", "Emergency Department", "appears to", "shock", "note", "penetrating wound", "level", "L3", "bullet", "level", "vascular structure", "injured"]}
{"question": "A clinical trial is conducted to test the efficacy of a new drug, A, to treat tinea versicolor. A total of 500 participants are recruited for the study and are randomized into 2 groups in equal numbers. Group 1, the study treatment group, is given drug A, while group 2, the control group, is given the current standard antifungal therapy. After the completion of therapy, 190 participants from the study treatment group and 165 participants from the control group are cured. Which calculation below represents the number needed to treat for the new drug?", "answer": "250/25", "options": {"A": "25/250", "B": "250/25", "C": "190/250", "D": "355/500"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["clinical trial", "conducted to test", "efficacy", "new drug", "to treat tinea versicolor", "total", "500 participants", "study", "randomized", "2 groups", "equal numbers", "Group 1", "study treatment group", "given drug", "group 2", "control group", "given", "current standard antifungal", "completion", "therapy", "participants", "study treatment group", "participants", "control group", "cured", "calculation", "represents", "number needed to treat", "new drug"]}
{"question": "A 38-year-old woman is being evaluated by her primary care physician for chronic, widespread pain that started around 5 months ago. This pain has been accompanied by sleeping issues. Her friend recommended that she try yoga to relieve the pain, but she says this has not helped her at all. Se says the symptoms have begun to impact her daily functions and keep her from doing things she used to enjoy. Past medical history includes generalized anxiety disorder, for which she currently takes no medication. The patient had been previously medicated with paroxetine for 5 years. On physical examination, several areas of point tenderness are found on the occipital region, elbows, and medial surface of both knees. Laboratory work up is unremarkable. What is the best treatment option for the most likely diagnosis in this patient?", "answer": "Paroxetine", "options": {"A": "Low-dose prednisolone", "B": "High-dose prednisolone", "C": "Paroxetine", "D": "Allopurinol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "evaluated", "primary care physician", "chronic", "widespread pain", "started", "months", "pain", "sleeping issues", "friend recommended", "yoga to relieve", "pain", "not helped", "Se", "symptoms", "begun", "impact", "daily functions", "keep", "things", "used", "Past medical history includes generalized anxiety disorder", "currently takes", "medication", "patient", "medicated", "paroxetine", "5 years", "physical examination", "several areas", "point tenderness", "found", "occipital region", "elbows", "medial surface of", "knees", "Laboratory work up", "unremarkable", "best treatment option", "likely diagnosis", "patient"]}
{"question": "A 3rd year resident in good standing with his residency training program would like to work more hours outside his residency obligations to gain more experience and pay for his medical school loans. He currently works and trains 60 hours per week as a resident and has a 10-hour shift external to his residency program on Saturdays. He is free of any educational and work obligations on Sundays. Based on the most recent standards set by the Accreditation Council for Graduate Medical Education (ACGME), which of the following is the most accurate statement regarding this resident’s moonlighting and patient safety?", "answer": "He may work longer shifts", "options": {"A": "He is already overcommitting and must reduce the number of hours", "B": "He is not allowed to work outside the scope of his residency training", "C": "He may work longer shifts", "D": "He may work up to 20 more hours"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["3rd year resident", "good standing", "residency training program", "to work more hours outside", "residency", "to gain more experience", "pay", "medical school loans", "currently works", "trains 60 hours per week", "resident", "a 10 hour shift external", "residency program", "Saturdays", "free", "educational", "work", "Sundays", "Based", "recent standards set", "Accreditation Council", "Graduate Medical Education", "following", "most accurate statement", "residents moonlighting", "patient safety"]}
{"question": "A 29-year-old man presents to the emergency department after a motor vehicle accident. On presentation, he is found to have scalp and trunk lacerations that are still actively bleeding. He has no past medical history and does not take any medications. On presentation, his temperature is 98.6°F (37°C), blood pressure is 110/74 mmHg, pulse is 82/min, and respirations are 17/min. On physical exam, he is found to be anxious but does not have any visible injuries other than the lacerations. Which of the following processes would most likely be seen in this patient?", "answer": "Increased norepinephrine at the sinoatrial node", "options": {"A": "Baroreceptor-mediated vasodilation", "B": "Increased acetylcholine at the sinoatrial node", "C": "Increased atrial natriuretic peptide release", "D": "Increased norepinephrine at the sinoatrial node"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["29 year old man presents", "emergency department", "motor vehicle accident", "presentation", "found to", "scalp", "trunk lacerations", "bleeding", "past medical history", "not take", "medications", "presentation", "temperature", "98", "blood pressure", "74 mmHg", "pulse", "min", "respirations", "min", "physical exam", "found to", "anxious", "not", "visible injuries", "lacerations", "following processes", "most likely", "seen", "patient"]}
{"question": "A 14-year-old teenager presents to his pediatrician complaining of frequent headaches and excessive fatigue during soccer practice. His mother notes that he seems to have gained a lot of weight despite the fact that he eats a healthy, well-balanced diet. His teachers have also become concerned because he leaves class to use the restroom frequently throughout the day. He has no medical problems and family history is insignificant. A physical exam is significant for a short, overweight child with nonpitting edema and decreased reflexes. His systolic blood pressure drops by 20 mm Hg when he stands. Fundoscopic exam is significant for papilledema and visual field exam is significant for bitemporal hemianopsia. Laboratory findings include:\nBUN 22 mg/dL N: 7–20 mg/dL\npCO2 32 mm Hg N: 35–45 mm Hg\nCreatinine 0.8 mg/dL N: 0.8–1.4 mg/dL\nGlucose 50 mg/dL N: 64–128 mg/dL\nSerum chloride 95 mmol/L N: 101–111 mmol/L\nSerum potassium 3.3 mEq/L N: 3.7–5.2 mEq/L\nSerum sodium 120 mEq/L N: 136–144 mEq/L\nBicarbonate (HCO3) 15 mmol/L N: 18–22 mmol/L\nThyroid-stimulating hormone (TSH) 0.1 mIU/L N: 0.5–5 mIU/L\nFree T4 6 pmol/L N: 10–20 pmol/L\nWhat is the necessary treatment?", "answer": "Surgical resection", "options": {"A": "Chemotherapy, surgical resection and radiation", "B": "Chemotherapy and radiation", "C": "Surgical resection", "D": "Hormone replacement therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old teenager presents", "pediatrician", "frequent headaches", "excessive fatigue", "soccer practice", "mother notes", "to", "gained", "lot", "weight", "eats", "healthy", "well balanced", "teachers", "concerned", "leaves class to use", "restroom frequently", "day", "medical problems", "family history", "physical exam", "significant", "short", "overweight child", "nonpitting edema", "decreased reflexes", "systolic blood pressure drops", "20 mm Hg", "stands", "Fundoscopic exam", "significant", "papilledema", "visual field exam", "significant", "bitemporal hemianopsia", "Laboratory findings include", "mg/dL", "720 mg/dL pCO2", "mm Hg", "mm Hg Creatinine 0.8 mg/dL", "0 81 4 mg dL Glucose 50 mg", "mg/dL Serum chloride 95 mmol/L", "mmol/L Serum potassium", "mEq", "3 75 2 mEq/L Serum sodium", "mEq/L Bicarbonate", "HCO3", "mmol/L", "mmol/L Thyroid-stimulating hormone", "0.1 mIU", "0 55 mIU/L Free T4 6 pmol", "pmol/L", "treatment"]}
{"question": "Hypoxia-inducible factor 1-alpha (HIF-1a) is a transcription factor with increased activity under conditions of cellular hypoxia. In normoxia, von Hippel-Lindau (VHL) protein hydroxylates prolyl residues on oxygen-dependent degradation domains of HIF-1a, targeting it for proteasomal degradation. Hydroxylation by VHL is inhibited under hypoxic conditions, allowing HIF-1a to escape degradation, dimerize with HIF-1ß, and translocate to the nucleus. This results in the upregulation of hypoxic response elements, leading to angiogenesis. Renal cell carcinoma (RCC) can mimic the hypoxic state to promote angiogenesis by inhibiting HIF-1a hydroxylation, even in the absence of hypoxia. A researcher wants to perform an experiment to detect HIF-1a in RCC under normoxic conditions with blotting techniques. Which of the following statements are most likely to be true regarding her experiment?", "answer": "A Western blot will show increased HIF-1α compared to a normoxic control.", "options": {"A": "A Northern blot will show increased HIF-1α, compared to a hypoxic control cell.", "B": "A Northern blot will show increased HIF-1α, compared to a normoxic control cell.", "C": "A Southern blot will show increased HIF-1α, compared to a normoxic control cell.", "D": "A Western blot will show increased HIF-1α compared to a normoxic control."}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Hypoxia-inducible factor 1-alpha", "transcription factor", "increased activity", "conditions", "cellular hypoxia", "protein", "residues", "oxygen dependent degradation domains", "HIF-1a", "targeting", "proteasomal degradation", "Hydroxylation", "inhibited", "hypoxic conditions", "allowing HIF-1a to escape degradation", "dimerize", "HIF-1", "nucleus", "results", "upregulation", "hypoxic response elements", "leading", "angiogenesis", "Renal cell carcinoma", "hypoxic state to promote angiogenesis", "inhibiting HIF-1a hydroxylation", "absence", "hypoxia", "researcher", "to perform", "experiment to detect HIF-1a", "RCC", "conditions", "techniques", "following statements", "most likely to", "true", "experiment"]}
{"question": "A 25-year-old primigravida is admitted to the hospital at 36 weeks gestation after a generalized tonic-clonic seizure. She is conscious, but lethargic and complains of a headache that started 2 hours prior to the seizure. She denies alcohol intake or drug use. She has no history of convulsive disorders and the antepartum course has been unremarkable. She was compliant with the recommended prenatal care and her last prenatal visit was 2 weeks ago. She has gained 2 kg (4.4 lb) since her last visit. The blood pressure was 160/90 mm Hg, the heart rate was 79/min, the respiratory rate was 14/min, and the temperature was 37.0℃ (98.6℉). The physical examination shows leg and perineal edema. The neurologic examination is significant for symmetric upper and lower extremity hyperreflexia and ankle clonus. Which of the following laboratory findings would be most common in this patient?", "answer": "Proteinuria", "options": {"A": "Elevated transaminases", "B": "Leukocytosis", "C": "Hyponatremia", "D": "Proteinuria"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old primigravida", "admitted", "hospital", "36 weeks gestation", "generalized tonic-clonic seizure", "conscious", "lethargic", "headache", "started 2 hours prior to", "seizure", "denies alcohol intake", "drug use", "history of convulsive disorders", "antepartum course", "unremarkable", "compliant", "recommended prenatal care", "last prenatal visit", "2 weeks", "gained 2 kg", "4.4", "last visit", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "0", "98", "physical examination shows leg", "perineal edema", "neurologic examination", "significant", "symmetric upper", "lower extremity hyperreflexia", "ankle clonus", "following laboratory findings", "most common", "patient"]}
{"question": "A 3-year-old male is brought by his mother to the pediatrician's office. The mother and child are refugees from Somalia and arrived in the United States one week ago. They were recently placed in temporary housing. The mother reports that the child has been chronically tired and subdued since before their arrival in the United States. The child was born at 38 weeks gestation with the help of a local midwife. The child’s temperature is 98.2°F (36.8°C), blood pressure is 105/60 mmHg, pulse is 90/min, and respirations are 18/min. Physical examination reveals a listless child with a rotund abdomen and positive fluid wave. Notable lower extremity edema is present. This patient's condition is most likely caused by a deficiency in which of the following?", "answer": "Relative protein intake", "options": {"A": "Total caloric intake", "B": "Relative protein intake", "C": "Relative carbohydrate intake", "D": "Relative fat intake"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 year old male", "brought", "mother", "pediatrician's office", "mother", "child", "refugees", "Somalia", "arrived", "United States one week", "recently placed", "temporary housing", "mother reports", "child", "tired", "since", "arrival", "United States", "child", "born", "weeks gestation", "help", "local midwife", "childs temperature", "98", "36", "blood pressure", "60 mmHg", "pulse", "90 min", "respirations", "min", "Physical examination reveals", "listless child", "abdomen", "positive fluid wave", "Notable lower extremity edema", "present", "patient's condition", "most likely caused", "deficiency", "following"]}
{"question": "A 42-year-old woman presents to her obstetrician for a prenatal care appointment at 10 weeks gestation. The patient recently found out she was pregnant after having unprotected intercourse with her husband for the past year. She states that she is feeling well and has experienced some nausea and vomiting. She is currently taking prenatal vitamins and folate supplements. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 19/min, and oxygen saturation is 98% on room air. On physical exam, you notice a gravid uterus 10 cm above the pubic symphysis. The patient's external genitalia appear within normal limits. Which of the following is the next best step in management?", "answer": "Cell-free DNA testing", "options": {"A": "Amniocentesis", "B": "Cell-free DNA testing", "C": "Chorionic villus sampling", "D": "Regular follow up appointments"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "obstetrician", "prenatal care appointment", "10 weeks gestation", "patient recently found out", "pregnant", "unprotected intercourse", "husband", "past year", "states", "feeling well", "experienced", "nausea", "vomiting", "currently taking prenatal vitamins", "folate supplements", "temperature", "99", "blood pressure", "68 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "physical exam", "gravid uterus 10", "pubic symphysis", "patient's external genitalia appear", "normal limits", "following", "next best step", "management"]}
{"question": "A 6-year-old boy is brought to the physician because of abdominal distention, fatigue, and night sweats over the past 4 months. He also has a 2-month history of post-prandial fullness and recurrent nonbilious vomiting. He appears pale. Abdominal examination shows hepatosplenomegaly and shifting dullness; there is mild tenderness to palpation. Examination of the skin shows multiple nonblanching maculae. A CT scan of the abdomen shows mesenteric and retroperitoneal lymph node enlargement and nodular thickening of the omentum. A photomicrograph of a biopsy specimen from an enlarged mesenteric lymph node is shown. Immunohistochemical staining of the Ki-67 nuclear antigen shows that the proliferation index of the specimen is > 99%. The structure indicated by the arrows is most likely which of the following?", "answer": "Macrophage", "options": {"A": "Neutrophil", "B": "Human immunodeficiency virus", "C": "B lymphocytes", "D": "Macrophage"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "physician", "abdominal distention", "fatigue", "night sweats", "past", "months", "2 month history", "post-prandial fullness", "recurrent", "vomiting", "appears pale", "Abdominal examination shows hepatosplenomegaly", "shifting dullness", "mild tenderness", "palpation", "Examination of", "skin shows multiple", "maculae", "CT scan", "abdomen shows mesenteric", "retroperitoneal lymph node enlargement", "nodular thickening", "omentum", "photomicrograph", "biopsy specimen", "enlarged mesenteric lymph node", "shown", "staining", "Ki-67 nuclear antigen shows", "proliferation index", "specimen", "99", "structure indicated", "arrows", "most likely", "following"]}
{"question": "A 14-year-old boy is brought to the emergency department by his mother after falling from the jungle gym and developing severe left knee pain and swelling. On presentation, he is found to be in pain with a hot, swollen, erythematous left knee. His past medical history is significant for abnormal coagulation lab tests before an appendectomy, but his mother cannot recall the exact details. Coagulation tests are conducted with the following results:\n\nBleeding time: 3 minutes\nProthrombin time: 11 seconds\nPartial thromboplastin time: 53 seconds\nBradykinin formation: decreased\n\nWhich of the following factors is most likely defective in this patient?", "answer": "Factor XII", "options": {"A": "Factor VII", "B": "Factor VIII", "C": "Factor IX", "D": "Factor XII"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old boy", "brought", "emergency department", "mother", "falling", "severe left knee pain", "swelling", "presentation", "found to", "pain", "hot", "swollen", "erythematous left", "past medical history", "significant", "abnormal coagulation lab tests", "appendectomy", "mother", "recall", "exact details", "Coagulation tests", "conducted", "following results", "Bleeding time", "3 minutes Prothrombin time", "seconds Partial thromboplastin time", "seconds Bradykinin formation", "decreased", "following factors", "most likely defective", "patient"]}
{"question": "A 52-year-old man with Crohn disease comes to the physician because of a 1-week history of dysuria and urinary urgency. He had been treated for urinary tract infections twice in the past 6 months. He is currently taking infliximab. Cystoscopy shows pearl-like plaques on the bladder wall. Biopsy of these lesions shows a focal layer of stratified squamous epithelium with hyperkeratosis. If the patient's bladder finding is caused by a vitamin deficiency, which of the following features is also most likely to be seen?", "answer": "Night blindness", "options": {"A": "Carpopedal spasm", "B": "Photodermatitis", "C": "Night blindness", "D": "Intracranial hypertension"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "Crohn disease", "physician", "1-week history", "dysuria", "urinary urgency", "treated", "urinary tract infections twice", "past 6 months", "currently taking infliximab", "Cystoscopy shows pearl like plaques", "bladder", "Biopsy", "lesions shows", "focal layer", "stratified squamous epithelium", "hyperkeratosis", "patient's bladder finding", "caused", "a vitamin deficiency", "following features", "likely to", "seen"]}
{"question": "A 26-year-old gravida 2 para 1 at 24 weeks gestation is admitted to the labor and delivery suite with mild abdominal cramps, uterine contractions, and a watery vaginal discharge. She has a history of preterm birth. The vital signs are as follows: blood pressure 125/80 mm Hg; heart rate 100/min; respiratory rate 13/min; and temperature 36.6℃ (97.9℉). The pelvic examination reveals cervical softening and shortening. Transvaginal ultrasound shows a cervical length of 12 mm, which is consistent with preterm labor. A tocolytic and a single dose of betamethasone are administered. Betamethasone stimulates which fetal cells?", "answer": "Type II pneumocytes", "options": {"A": "Goblet cells", "B": "Bronchial epithelial cells", "C": "Type II pneumocytes", "D": "Vascular smooth myocytes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old gravida", "weeks", "admitted", "labor", "delivery suite", "mild abdominal cramps", "uterine contractions", "watery vaginal discharge", "history", "preterm birth", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate 100 min", "respiratory rate", "min", "temperature 36", "97", "pelvic examination reveals cervical softening", "shortening", "Transvaginal ultrasound shows", "cervical length", "mm", "consistent with preterm labor", "tocolytic", "single dose", "betamethasone", "administered", "Betamethasone", "fetal cells"]}
{"question": "A 55-year-old man is brought to the emergency department after collapsing at the grocery store and losing consciousness for 1 minute following a sudden onset of palpitations. He has no chest pain or dizziness. He has a history of hypertension, type 2 diabetes mellitus, and is currently being treated as an outpatient for pneumonia. His current medications include lisinopril, metformin, and azithromycin. He has no sign of injury, and he appears well. During the examination, he loses consciousness again. Telemetry shows polymorphic ventricular tachycardia with cyclic alteration of the QRS axis, which spontaneously resolves after 30 seconds. Which of the following is the most likely underlying cause of this patient's syncope?", "answer": "Prolonged QT interval", "options": {"A": "Hypomagnesemia", "B": "Brugada syndrome", "C": "Prolonged QT interval", "D": "Hyperkalemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["55 year old man", "brought", "emergency department", "collapsing", "grocery store", "consciousness", "minute following", "sudden onset", "palpitations", "chest pain", "dizziness", "history of hypertension", "type 2 diabetes mellitus", "currently", "treated", "outpatient", "pneumonia", "current medications include lisinopril", "metformin", "azithromycin", "sign", "injury", "appears well", "examination", "consciousness", "Telemetry shows polymorphic ventricular tachycardia", "cyclic alteration", "QRS axis", "resolves", "30 seconds", "following", "most likely underlying cause", "patient's syncope"]}
{"question": "A 56-year-old patient is being treated with oral amoxicillin for community-acquired pneumonia. The plasma clearance of the drug is calculated as 15.0 L/h. Oral bioavailability of the drug is 75%. Sensitivity analysis of a sputum culture shows a minimal inhibitory concentration of 1 μg/mL for the causative pathogen. The target plasma concentration is 2 mg/L. If the drug is administered twice per day, which of the following dosages should be administered at each dosing interval to maintain a steady state?", "answer": "480 mg", "options": {"A": "270 mg", "B": "480 mg", "C": "240 mg", "D": "540 mg\n\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old patient", "treated with oral amoxicillin", "community-acquired pneumonia", "plasma clearance", "drug", "calculated", "15.0 L/h", "Oral bioavailability of", "drug", "75", "Sensitivity analysis", "sputum shows", "minimal inhibitory concentration", "1 mL", "pathogen", "target plasma concentration", "2 mg/L", "drug", "administered twice per day", "following dosages", "administered", "dosing interval to maintain", "steady state"]}
{"question": "A 5-year-old boy is brought to his pediatrician’s office by his parents after they noticed blood in his urine. The child has been complaining of difficulty in passing urine and has lower abdominal pain. He seems more bloated than usual. On some occasions, he starts crying while passing urine, primarily because of a burning sensation. A urinalysis is performed, and the results are as follows:\nUrine pH 6.2\nUrine specific gravity 1.010\nGlucose Negative\nKetones Negative\nRBCs 1-2/hpf\nWBCs 0-1/hpf\nCasts 2-3/hpf\nThe pediatrician believes the boy has a bladder infection with a double-stranded DNA virus. Which of the following conditions is also commonly associated with this viral infection?", "answer": "Gastroenteritis", "options": {"A": "Gastroenteritis", "B": "Painful dermatomal vesicles", "C": "Lymphadenopathy", "D": "Vesicular rash"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["5 year old boy", "brought", "pediatricians office", "parents", "blood in", "urine", "child", "difficulty", "passing urine", "lower abdominal pain", "more bloated", "usual", "occasions", "starts crying", "passing urine", "burning sensation", "urinalysis", "performed", "results", "follows", "Urine pH 6", "specific gravity", "Glucose Negative Ketones", "RBCs", "hpf", "0", "Casts 2-3 hpf", "pediatrician", "boy", "bladder infection", "double-stranded DNA virus", "following conditions", "associated", "viral infection"]}
{"question": "A 46-year-old woman presents with difficulty initiating sleep, as well as frequent nighttime awakenings. She reports making multiple mistakes at her office job, has an inability to concentrate, and feels sleepy throughout the day. She is worried that her sleeping troubles will cause her to get fired. Which of the following would best treat this patient’s insomnia pharmacologically?", "answer": "Triazolam", "options": {"A": "Chlordiazepoxide", "B": "Triazolam", "C": "Diazepam", "D": "Modafinil"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "difficulty initiating sleep", "frequent nighttime awakenings", "reports making multiple mistakes", "office job", "to concentrate", "feels sleepy", "day", "worried", "sleeping", "cause", "to", "fired", "following", "best treat", "patients insomnia"]}
{"question": "A 5-year-old girl is brought to her pediatrician for evaluation of difficulties noted at school. Her kindergarten teacher voiced her concern that the child ‘spaces out’ often and thinks she may have ADHD. The parents deny any history of head trauma or infection. Her blood pressure is 106/74 mm Hg, the heart rate is 69/min, and the respiratory rate is 14/min. Physical exam demonstrates a happy child who has reached developmental milestones. Laboratory results are within normal limits. EEG demonstrates a 3-Hz spike and wave pattern (see image). The decision is made to start the child on medical therapy. What should be advised to the parents as a potential side effect of the first-line medication?", "answer": "GI upset", "options": {"A": "Nystagmus", "B": "GI upset", "C": "Facial rash and blood in the urine", "D": "Weight gain and change in hair color"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["5 year old girl", "brought", "pediatrician", "evaluation", "difficulties noted", "school", "kindergarten teacher voiced", "concern", "child spaces out often", "thinks", "ADHD", "parents deny", "history", "head trauma", "infection", "blood pressure", "74 mm Hg", "heart rate", "69 min", "respiratory rate", "min", "Physical exam demonstrates", "happy child", "reached developmental milestones", "Laboratory results", "normal", "EEG demonstrates", "3 Hz", "wave pattern", "see image", "decision", "made to start", "child", "medical therapy", "parents", "potential side effect", "first line medication"]}
{"question": "A 75-year-old man comes to the physician for the evaluation of progressive shortness of breath and fatigue over the past month. He reports that he cannot climb more than one flight of stairs without experiencing shortness of breath and dizziness. He has hypertension and hyperlipidemia. He has smoked one pack of cigarettes daily for the past 50 years. He does not drink alcohol. His medications include enalapril, atorvastatin, and low-dose aspirin. His temperature is 37°C (98.6°F), pulse is 70/min, respirations are 18/min, and blood pressure is 100/80 mm Hg. Physical examination shows weak peripheral pulses. Cardiac examination is shown. Which of the following is the most likely diagnosis?", "answer": "Aortic valve stenosis", "options": {"A": "Tricuspid valve stenosis", "B": "Mitral valve prolapse", "C": "Mitral valve stenosis", "D": "Aortic valve stenosis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["75 year old man", "physician", "evaluation of progressive shortness", "breath", "fatigue", "past month", "reports", "climb more", "one flight", "stairs", "experiencing shortness of breath", "dizziness", "hypertension", "hyperlipidemia", "smoked one pack", "cigarettes daily", "past 50 years", "not drink alcohol", "medications include enalapril", "atorvastatin", "low-dose aspirin", "temperature", "98", "pulse", "70 min", "respirations", "min", "blood pressure", "100 80 mm Hg", "Physical examination shows weak peripheral pulses", "Cardiac examination", "shown", "following", "most likely diagnosis"]}
{"question": "A 56-year-old man comes to the physician for a follow-up examination 1 week after a temporal artery biopsy was performed to evaluate headache and blurry vision. He has a 12-year history of hypertension treated with lisinopril. Results of the testing show decreased concentrations of arginine in vascular endothelial cells. Which of the following is the most likely explanation for this finding?", "answer": "Increased production of nitric oxide", "options": {"A": "Increased binding of calcium to calmodulin", "B": "Increased phosphorylation of myosin", "C": "Increased production of nitric oxide", "D": "Decreased concentration of bradykinin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "follow-up examination 1 week", "temporal artery biopsy", "performed to evaluate headache", "blurry vision", "year history of hypertension treated with lisinopril", "Results", "testing show decreased concentrations", "arginine", "vascular endothelial cells", "following", "most likely explanation", "finding"]}
{"question": "While traveling abroad a physician is asked to attend a meeting regarding healthcare in the region. The rate of chlamydial infection is exceptionally high in the area, and the local government is wanting to test a new treatment for these infections. To test the new therapy, the physician is asked to oversee the operations of testing this new treatment. When asking what this would entail, the officials tell the physician that they plan to infect the local prison population with chlamydia and then test the new treatment on these individuals. Which of the following is the best response from the physician?", "answer": "“I can not help you due to the ethical principle of nonmaleficence.”", "options": {"A": "“I can not help you due to the ethical principle of autonomy.”", "B": "“I can not help you due to the ethical principle of justice.”", "C": "“I can not help you due to the ethical principle of nonmaleficence.”", "D": "“I can not help you due to the ethical principle of beneficence.”"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["traveling abroad", "physician", "to attend", "meeting", "healthcare", "region", "rate", "chlamydial infection", "high", "area", "local government", "to test", "new treatment", "infections", "To test", "new therapy", "physician", "to", "operations", "testing", "new treatment", "officials", "physician", "plan to infect", "local prison population", "chlamydia", "then test", "new treatment", "individuals", "following", "best response", "physician"]}
{"question": "A 48-year-old woman comes to the physician because of a 7-day history of progressively worsening shortness of breath. She has a history of asthma and has frequent exacerbations despite receiving maximal medical therapy. Physical examination shows scattered expiratory wheezing. Laboratory studies show a leukocyte count of 9,800/mm3 (13% eosinophils) and elevated serum concentration of immunoglobulin E. An x-ray of the chest shows thickened bronchial walls and perihilar opacities. Sputum culture shows scattered septate hyphae that branch at 45 degrees. Which of the following is most likely to be increased in this patient?", "answer": "IL-4", "options": {"A": "IL-28", "B": "TGF-β", "C": "IFN-α", "D": "IL-4"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["48 year old woman", "physician", "7-day history", "worsening shortness of breath", "history of asthma", "frequent exacerbations", "receiving maximal medical therapy", "Physical examination shows scattered expiratory wheezing", "Laboratory studies show", "leukocyte count", "9 800 mm3", "eosinophils", "elevated serum concentration", "immunoglobulin E", "x-ray of", "chest shows thickened bronchial walls", "opacities", "Sputum culture shows scattered septate hyphae", "branch", "degrees", "following", "most likely to", "increased", "patient"]}
{"question": "A 29-year-old G1P0 female presents at 22 weeks gestation for her first prenatal care appointment. Physical exam demonstrates a uterine size greater than expected for her gestational age and taut, shiny skin with scattered striae on her abdomen. Ultrasound examination of the fetus reveals 2.5 L of amniotic fluid (normal 1.5-2.0 L) with an amniotic fluid index (AFI) of 34 (normal AFI 20-25). Which of the following fetal abnormalities or dysfunctions could have contributed to these abnormal ultrasound findings?", "answer": "Duodenal atresia", "options": {"A": "Renal agenesis", "B": "Pulmonary hypoplasia", "C": "Duodenal atresia", "D": "Posterior urethral valve"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old", "female presents", "weeks gestation", "first prenatal care appointment", "Physical exam demonstrates", "uterine size greater than expected", "gestational age", "taut", "shiny", "scattered striae", "abdomen", "Ultrasound examination", "fetus reveals 2.5", "of amniotic fluid", "normal", "amniotic fluid index", "normal AFI 20-25", "following fetal abnormalities", "dysfunctions", "contributed", "abnormal ultrasound findings"]}
{"question": "A 68-year-old woman presents to the emergency room with chest pain. She reports sudden severe and crushing substernal chest pain that started 1 hour ago. Her past medical history is notable for hypertension, hyperlipidemia, diabetes mellitus, obesity, and a prior myocardial infarction requiring a coronary artery bypass graft 2 years ago. She takes aspirin, metoprolol, lisinopril, spironolactone, atorvastatin, and insulin. She is retired and lives a sedentary lifestyle at home. Her temperature is 98.8°F (37.1°C), blood pressure is 109/68 mmHg, pulse is 118/min, and respirations are 24/min. Before being able to start the physical examination, the patient loses consciousness. Her pulse is palpable but weak. Her blood pressure is now 88/50 mmHg and pulse is 130/min. Her skin is pale, cold, and clammy. An electrocardiogram demonstrates ST elevations in leads I, aVL, V3, V4, V5, and V6. A medication that primarily stimulates which of the following receptors would be most appropriate to improve the hemodynamic status of this patient?", "answer": "Beta-1 adrenergic receptor", "options": {"A": "Alpha-2 adrenergic receptor", "B": "Beta-1 adrenergic receptor", "C": "Beta-2 adrenergic receptor", "D": "D2 receptor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["68 year old woman presents", "emergency room", "chest pain", "reports sudden severe", "crushing", "chest pain", "started 1 hour", "past medical history", "notable", "hypertension", "hyperlipidemia", "diabetes mellitus", "obesity", "prior myocardial infarction", "coronary artery bypass graft", "years", "takes aspirin", "metoprolol", "lisinopril", "spironolactone", "atorvastatin", "insulin", "retired", "lives", "sedentary lifestyle at home", "temperature", "98", "blood pressure", "68 mmHg", "pulse", "min", "respirations", "min", "able to start", "physical examination", "patient", "consciousness", "pulse", "palpable", "weak", "blood pressure", "now 88 50 mmHg", "pulse", "min", "skin", "pale", "cold", "clammy", "electrocardiogram demonstrates ST elevations", "leads I", "aVL", "V3", "V4", "V5", "V6", "medication", "following receptors", "most appropriate to", "hemodynamic status", "patient"]}
{"question": "A 4-year-old child is rushed to the emergency department after developing sudden abdominal pain followed by nausea, vomiting, and dark, almost black-colored stool. Prior to the onset of symptoms, he was seen playing with his mother’s purse containing a bottle of vitamin supplements, which she takes for chronic microcytic anemia. Which of the following medications is the treatment for this patient's intoxication?", "answer": "Deferoxamine", "options": {"A": "Dimercaprol", "B": "Deferoxamine", "C": "Protamine", "D": "Succimer"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old child", "rushed", "emergency department", "sudden abdominal pain followed by nausea", "vomiting", "dark", "almost black-colored stool", "Prior to", "onset", "symptoms", "seen playing", "mothers", "containing a bottle", "vitamin supplements", "takes", "chronic microcytic", "following medications", "treatment", "patient's intoxication"]}
{"question": "A 32-year-old woman comes to the physician because of fatigue, breast tenderness, increased urinary frequency, and intermittent nausea for 2 weeks. Her last menstrual period was 7 weeks ago. She has a history of a seizure disorder treated with carbamazepine. Physical examination shows no abnormalities. A urine pregnancy test is positive. The child is at greatest risk of developing which of the following complications?", "answer": "Meningocele", "options": {"A": "Renal dysplasia", "B": "Meningocele", "C": "Sensorineural hearing loss", "D": "Vaginal clear cell carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "fatigue", "breast tenderness", "increased urinary frequency", "intermittent nausea", "2 weeks", "last menstrual period", "weeks", "history of", "seizure disorder treated with carbamazepine", "Physical examination shows", "abnormalities", "urine pregnancy test", "positive", "child", "greatest risk", "following complications"]}
{"question": "Three patients present to the pediatrician for routine well-child visits. The first child’s mother reports that he seems to be breastfeeding well and voids at least eight times per day. His stools are a yellow color, and he does not seem to be straining. In the office, he can lift his head and chest when in the prone position, and he can track an object with his eyes to the midline. His hands remain fisted 50% of the time.\n\nThe second child’s parents report that she is doing well at home and seems to enjoy playing with her older brother. In the office, she can roll from supine to prone and can transfer her rattle from hand to hand. She cannot yet say any words.\n\nThe third child’s father reports that he is starting to explore the world around him. He has begun taking independent steps at home. In the office, he seems to recognize the name of several objects, but he cannot follow the direction to “grab the ball.” All three children are assessed as developmentally normal.\n\nWhich of the following represents these patient's respective ages?", "answer": "Ages 2 months, 6 months, and 12 months", "options": {"A": "Ages 1 month, 4 months, and 9 months", "B": "Ages 2 months, 4 months, and 12 months", "C": "Ages 2 months, 6 months, and 9 months", "D": "Ages 2 months, 6 months, and 12 months"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Three patients present", "pediatrician", "routine well-child visits", "first childs mother reports", "to", "breastfeeding well", "voids", "eight times per day", "stools", "yellow color", "not", "to", "straining", "office", "lift", "head", "chest", "prone position", "track", "object", "eyes", "midline", "hands", "fisted 50", "time", "second childs parents report", "well", "home", "playing", "older brother", "office", "supine", "prone", "transfer", "hand", "words", "third childs father reports", "starting to", "world", "begun taking independent steps at home", "office", "to", "name", "objects", "follow", "direction to grab", "ball", "three children", "assessed", "normal", "following represents", "patient's", "ages"]}
{"question": "A 75-year-old woman presents to the emergency department with 30 minutes of slurred speech and arm weakness. On the drive over to the hospital, her symptoms have resolved completely. The patient has a past medical history of hypertension, atrial fibrillation, diabetes, morbid obesity, gout, and vascular claudication. Her temperature is 99.0°F (37.2°C), blood pressure is 184/111 mmHg, pulse is 88/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals cranial nerves II-XII as grossly intact with normal strength and sensation in the patient's upper and lower extremities. The patient's memory is intact and her speech seems normal and fluent. Her gait is stable with no ataxia. An initial head CT demonstrates diffuse atrophy which is consistent with previous head CT scans. Which of the following is the best next step in management?", "answer": "CT angiogram", "options": {"A": "CT angiogram", "B": "Echocardiogram", "C": "Heparin", "D": "MRI"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["75 year old woman presents", "emergency department", "30 minutes", "slurred speech", "arm weakness", "drive", "hospital", "symptoms", "resolved completely", "patient", "past medical", "atrial fibrillation", "diabetes", "morbid obesity", "gout", "vascular claudication", "temperature", "99", "blood pressure", "mmHg", "pulse", "88 min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam reveals cranial nerves II XII", "intact", "normal strength", "sensation", "patient's upper", "lower extremities", "patient's memory", "intact", "speech", "normal", "fluent", "gait", "stable", "ataxia", "initial head CT demonstrates diffuse atrophy", "consistent with previous head CT scans", "following", "best next step", "management"]}
{"question": "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?", "answer": "Antitoxin", "options": {"A": "Antitoxin", "B": "Neostigmine", "C": "Plasmapheresis", "D": "Riluzole"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "weakness", "states", "started", "worsening", "Initially", "blurry vision", "speaking", "swallowing", "thought", "cold", "then", "weakness", "facial muscles", "shortness of breath", "patient works", "farmer", "harvests", "cans", "foods", "diarrhea recently", "cough prior to", "symptoms", "weakness", "temperature", "97 9F", "36", "blood pressure", "mmHg", "pulse", "87 min", "respirations", "min", "oxygen saturation", "room air", "Physical exam", "notable", "man", "unable", "smile", "dysarthric speech", "takes shallow", "weak breaths", "pulmonary exam", "patient demonstrates 3/5 strength", "diminished reflexes", "upper extremities", "patient", "intubated", "following", "best treatment", "patient"]}
{"question": "A 79-year-old woman comes to the physician because of a 1-month history of difficulty starting urination and a vague sensation of fullness in the pelvis. Pelvic speculum examination in the lithotomy position shows a pink structure at the vaginal introitus that protrudes from the anterior vaginal wall when the patient is asked to cough. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Cystocele", "options": {"A": "Vaginal rhabdomyosarcoma", "B": "Cystocele", "C": "Rectocele", "D": "Uterine leiomyomata"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "month history", "difficulty starting urination", "vague sensation", "fullness", "pelvis", "speculum examination", "lithotomy position shows", "pink structure", "vaginal introitus", "anterior vaginal wall", "patient", "to cough", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 30-year-old woman presents to the physician because of ongoing diarrhea for the past 1 month. She reports that diarrhea has been intermittently present for the past month. The stool is often loose and associated with blood and lower abdominal pain. She denies any recent travel history, and she works at a nursing home as a caretaker. She is not currently on any medications. Clinical examination shows mild tenderness in the suprapubic region, and there is no organomegaly. Findings on colonoscopy include patchy erythema and ulceration in the cecum, ascending, descending, and sigmoid colon. Mucosal biopsy shows colonic crypts with lymphocytic and neutrophilic infiltrates. What is the most likely diagnosis?", "answer": "Crohn’s disease", "options": {"A": "Crohn’s disease", "B": "Acute infective colitis", "C": "Pseudomembranous colitis", "D": "Irritable bowel syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "physician", "of ongoing diarrhea", "past", "month", "reports", "diarrhea", "present", "past month", "stool", "often loose", "associated with blood", "lower abdominal pain", "denies", "recent travel history", "works at", "nursing home", "caretaker", "not currently", "medications", "Clinical examination shows mild tenderness", "suprapubic region", "organomegaly", "Findings", "colonoscopy include patchy erythema", "ulceration", "cecum", "ascending", "descending", "sigmoid colon", "Mucosal biopsy shows colonic crypts", "lymphocytic", "neutrophilic infiltrates", "most likely diagnosis"]}
{"question": "A 45-year-old man presents to the emergency department after being stabbed 12 times in various parts of his body. Paramedics report extensive blood loss at the scene where he was found. Due to his Glasgow Coma Scale score of 3, an endotracheal airway and large-bore access are secured prior to arrival. He is aggressively resuscitated with a massive transfusion protocol as the operating room is prepared for an exploratory laparotomy. An arterial line and central access are obtained. His temperature is 95°F (35°C), blood pressure is 50/40 mmHg, and pulse is 80/min, and respirations are controlled at 20/min on lung-protective volume control. After a 6:6:1 ratio of red blood cells, plasma, and platelets and the use of continuous phenylephrine infusion, the patient's vital signs remain the same. The surgical team reports no active blood loss. A stat ScvO2 results as 39% with a SaO2 of 100% on 100% oxygen. His extremities remain cold despite having the ambient room temperature increased to 80°F (26.7°C). What is the most likely cause of his presentation?", "answer": "Cardiac tamponade", "options": {"A": "Cardiac tamponade", "B": "Cervical spinal cord transection", "C": "Pulmonary embolism", "D": "Undiagnosed pneumonia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "stabbed", "times", "various parts of", "body", "Paramedics report extensive blood loss", "found", "Due to", "Glasgow Coma Scale score", "3", "endotracheal airway", "large bore access", "secured prior to arrival", "resuscitated", "massive transfusion protocol", "operating room", "prepared", "exploratory laparotomy", "arterial line", "central access", "obtained", "temperature", "blood pressure", "50 40 mmHg", "pulse", "80 min", "respirations", "controlled", "20 min", "lung", "volume", "1 ratio", "red blood cells", "plasma", "platelets", "use of continuous phenylephrine infusion", "patient's vital signs", "same", "surgical team reports", "active blood loss", "stat", "results", "100", "100", "oxygen", "extremities", "cold", "ambient room increased", "most likely cause", "presentation"]}
{"question": "A 71-year-old woman presents to her physician accompanied by her son. She has no complaints, but her son states that the patient has impaired memory and poor orientation in space. She is ambulatory and is capable of self-care, but she tends to forget newly introduced information. Also, she got lost on the way from the home to the local market several times for the past 6 months, and her family is now afraid to let her go anywhere on her own. She does not have any concomitant chronic conditions nor did she have major cardiovascular events or head trauma. It is known that her father had dementia. The vital signs include: blood pressure is 130/80 mm Hg, heart rate is 62/min, respiratory rate is 11/min, and the temperature is 36.5°C (97.7°F). The respiratory, cardiologic, and abdominal examinations are unremarkable. The neurological examination shows equal, round pupils with a normal reaction to light. The eye movements are normal with no nystagmus and normal oculocephalic reflex. There is no facial droop, the facial sensation is preserved, and there is no tongue deviation noted. There is no motor or sensory deficits on the upper and lower extremities. The patient scores 18 on the Montreal Cognitive Assessment. Which of the following medications is indicated in the patient?", "answer": "Donepezil", "options": {"A": "Imipramine", "B": "Lithium", "C": "Donepezil", "D": "Sulpiride"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["71 year old woman presents", "physician", "son", "complaints", "son states", "patient", "impaired memory", "poor orientation", "space", "ambulatory", "capable", "self-care", "forget newly introduced information", "got lost", "home", "local market", "times", "past 6 months", "family", "now afraid to let", "go", "not", "concomitant chronic conditions", "major cardiovascular events", "head trauma", "known", "father", "dementia", "vital signs include", "blood pressure", "80 mm Hg", "heart rate", "62 min", "respiratory rate", "min", "temperature", "36", "97", "respiratory", "cardiologic", "abdominal examinations", "unremarkable", "neurological examination shows equal", "round pupils", "normal reaction", "light", "eye movements", "normal", "nystagmus", "normal", "reflex", "facial droop", "facial sensation", "preserved", "tongue deviation noted", "motor", "sensory deficits", "upper", "lower extremities", "patient scores", "Montreal Cognitive Assessment", "following medications", "indicated", "patient"]}
{"question": "A 16-year-old teenager presents to the emergency department with a sudden onset of severe pain in his right knee. He describes the pain as the worst pain he has ever felt. He denies any recent trauma or injury to the knee. The joint appears red and swollen and is hot to the touch. He denies any lower extremity numbness. There is no family history of joint or connective tissue disorders. The teenager is otherwise healthy. On physical examination, his blood pressure is 124/82 mm Hg, respirations are 17/min, pulse is 104/min, and temperature is 39.1°C (102.4°F). On palpation of the affected joint, there is evidence of tenderness and capsular swelling; the joint is red and warm. Laboratory studies show increased serum CRP and procalcitonin levels. Which of the following will most likely found with analysis of his synovial fluid?", "answer": "WBC/mm3 53,000; % PMN > 75%; Viscosity low", "options": {"A": "WBC/mm3 1,600; % PMN > 25%; Viscosity N", "B": "WBC/mm3 53,000; % PMN > 75%; Viscosity low", "C": "WBC/mm3 160; % PMN < 20%; Viscosity high", "D": "WBC/mm3 2,400; % PMN < 20%; Viscosity low"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old teenager presents", "emergency department", "sudden onset", "severe pain", "right knee", "pain", "worst", "felt", "denies", "recent trauma", "injury", "knee", "joint appears red", "swollen", "hot", "touch", "denies", "lower extremity numbness", "family history", "joint", "connective tissue disorders", "teenager", "healthy", "physical examination", "blood pressure", "mm Hg", "respirations", "min", "pulse", "min", "temperature", "4F", "palpation", "affected joint", "evidence", "tenderness", "capsular swelling", "joint", "red", "warm", "Laboratory studies show increased serum CRP", "procalcitonin levels", "following", "most likely found", "analysis", "synovial fluid"]}
{"question": "An otherwise healthy 49-year-old woman has a routine full blood count complete prior her elective cholecystectomy. The lab test results are as follows:\nLaboratory test\nHemoglobin\n12.1 g/dL\nMean corpuscular volume (MCV)\n85 μm3\nMean corpuscular hemoglobin concentration (MCHC)\n47%\nReticulocyte count\n3.4 %\nWhite blood cell count\n9700/mm3\nPlatelet count\n229,000/mm3\nA peripheral blood smear reveals spherocytes. The Coombs test is negative. The physical examination is remarkable for scleral icterus and moderate splenomegaly. Which of the following is the most appropriate diagnostic test of this patient’s underlying disorder?", "answer": "Eosin-5-maleimide binding test", "options": {"A": "Eosin-5-maleimide binding test", "B": "Flow cytometry for CD55/CD59", "C": "Anti parvovirus B19 antibodies", "D": "Liver function tests"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old woman", "routine full blood count complete prior", "elective cholecystectomy", "lab test results", "follows", "Laboratory test Hemoglobin", "g", "Mean corpuscular volume", "85", "Reticulocyte count", "blood", "mm3 Platelet count", "peripheral blood smear reveals spherocytes", "Coombs test", "negative", "physical examination", "scleral icterus", "moderate splenomegaly", "following", "most appropriate diagnostic test", "patients", "disorder"]}
{"question": "A 39-year-old man is brought to the physician by his wife because of personality changes over the past year. He has become increasingly irritable, loud, aggressive, and impulsive. His wife also reports jerky movements of his limbs and trunk for the past few months. His father had dementia in his mid-40s, but the details of his condition are unclear. The patient appears restless. Examination shows irregular movements of the extremities and twitching of the face and tongue. Mental status examination shows impaired memory. This patient's condition is most likely associated with which of the following changes on MRI?", "answer": "Atrophy of the striatum", "options": {"A": "Reduced hippocampal volume", "B": "Multiple cortical and subcortical infarctions", "C": "Degeneration of the frontal and temporal lobes", "D": "Atrophy of the striatum"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "brought", "physician", "wife", "personality changes", "past year", "irritable", "loud", "aggressive", "impulsive", "wife", "reports jerky movements", "limbs", "trunk", "past", "months", "father", "dementia", "details", "condition", "patient appears restless", "Examination shows irregular movements", "extremities", "twitching of", "face", "tongue", "Mental shows impaired memory", "patient's condition", "most likely associated with", "following changes", "MRI"]}
{"question": "A 45-year-old African-American woman comes to the physician after an episode of hemoptysis. Over the past 8 months, she has had a nonproductive cough, fatigue, and a 9-kg (20-lb) weight loss. She drinks a glass of wine every night and does not smoke. She has a history of hypertension and osteoarthritis. She does not take any medications. She has never traveled out of the country. She works as an accountant. Her temperature is 37.0°C (98.6°F), pulse is 94/min, and blood pressure is 130/90 mm Hg. Lungs are clear to auscultation. An x-ray of the chest shows a 2.5-cm nodule with irregular borders at the apex of the left lung with no mediastinal or hilar enlargement. Which of the following is the most likely diagnosis?", "answer": "Adenocarcinoma of the lung", "options": {"A": "Carcinoid tumor", "B": "Sarcoidosis", "C": "Squamous cell carcinoma of the lung", "D": "Adenocarcinoma of the lung"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old African-American woman", "physician", "episode of hemoptysis", "past", "months", "nonproductive cough", "fatigue", "kg", "20", "weight loss", "drinks", "glass", "wine", "night", "not smoke", "history of hypertension", "osteoarthritis", "not take", "medications", "never traveled out", "country", "works", "accountant", "temperature", "98", "pulse", "min", "blood pressure", "90 mm Hg", "Lungs", "clear", "auscultation", "x-ray of", "chest shows", "2.5", "nodule", "irregular borders", "apex of", "left lung", "mediastinal", "hilar enlargement", "following", "most likely diagnosis"]}
{"question": "A 70-year-old man with hyperlipidemia and hypertension returns to his cardiologist for ongoing blood pressure management. He reports feeling fine with no trouble with his medications. He exercises regularly and sleeps well without snoring or daytime somnolence. His blood pressure measurements in the past have ranged from 160 - 170/80 - 100 mmHg. Today, his pressure is 150/100 mmHg with a pulse of 65/min while on hydrochlorothiazide and ramipril. Physical exam reveals a II/VI early systolic murmur with split S2 is appreciated at the right upper sternal border. There is unremarkable carotid, renal, or abdominal bruits. What is the most common cause of his hypertension?", "answer": "Stiffening of the aorta", "options": {"A": "Primary hyperaldosteronism", "B": "Hypothyroidism", "C": "Stiffening of the aorta", "D": "Aortic stenosis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old man", "hyperlipidemia", "hypertension returns", "cardiologist", "ongoing blood", "reports feeling fine", "medications", "exercises", "sleeps well", "snoring", "daytime somnolence", "blood pressure measurements", "past", "ranged", "80", "100 mmHg", "Today", "pressure", "100 mmHg", "pulse", "65 min", "hydrochlorothiazide", "ramipril", "Physical exam reveals", "II VI early systolic murmur", "split S2", "right upper sternal border", "unremarkable carotid", "renal", "abdominal bruits", "most common cause", "hypertension"]}
{"question": "An 11-month-old boy is brought to the physician for a well-child examination. He is growing along with the 75th percentile and meeting all milestones. Physical examination shows a poorly rugated scrotum. The palpation of the scrotum shows only 1 testicle. A 2nd testicle is palpated in the inguinal canal. The examination of the penis shows a normal urethral meatus. The remainder of the physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Orchiopexy", "options": {"A": "Chorionic gonadotropin therapy", "B": "Exploratory laparoscopy", "C": "Orchiectomy", "D": "Orchiopexy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["month old boy", "brought", "physician", "well", "percentile", "meeting", "milestones", "Physical examination shows", "poorly", "scrotum", "palpation", "scrotum shows only", "testicle", "2nd testicle", "palpated", "inguinal canal", "examination of", "penis shows", "normal urethral meatus", "physical examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 24-year-old woman comes to the physician because of 1-day history of nausea and weakness. She has no history of serious illness. She is sexually active with 2 male partners and uses an oral contraceptive; she uses condoms inconsistently. Her last menstrual period was 4 days ago. Her temperature is 37.8°C (100°F), pulse is 88/min, respirations are 18/min, and blood pressure is 115/70 mm Hg. Physical examination shows right costovertebral angle tenderness. The abdomen is soft and nontender. Cardiopulmonary examination shows no abnormalities. Laboratory studies show:\nHemoglobin 14 g/dL\nLeukocyte count 13,000/mm3\nPlatelet count 250,000/mm3\nSerum\nUrea nitrogen 18 mg/dL\nCreatinine 0.8 mg/dL\nGlucose 95 mg/dL\nC-reactive protein 16.4 mg/L (N=0.08–3.1)\nWhich of the following is the most appropriate next step in management?\"", "answer": "Urinalysis", "options": {"A": "Urinalysis", "B": "Cervical swab", "C": "Blood culture", "D": "CT scan of the abdomen\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "1-day history", "nausea", "weakness", "history", "serious illness", "sexually active", "male partners", "uses", "oral contraceptive", "uses condoms", "last menstrual period", "4 days", "temperature", "pulse", "88 min", "respirations", "min", "blood pressure", "70 mm Hg", "Physical examination shows right costovertebral angle tenderness", "abdomen", "soft", "nontender", "Cardiopulmonary examination shows", "abnormalities", "Laboratory studies show", "Hemoglobin", "Leukocyte", "Platelet count", "Creatinine", "protein 16 4", "L", "N 0", "1", "following", "most appropriate next step", "management"]}
{"question": "A 65-year-old woman comes to the physician for a routine bone mineral density screening. She does not have any children. Menopause was at age 55. Her mother died of breast cancer at the age of 48 years. She has hypertension for which she takes ramipril. Dual-energy x-ray absorptiometry at the femoral neck shows a T-score of -2.7 SD. The physician considers treatment with raloxifene. This medication would put her at increased risk of developing which of the following conditions?", "answer": "Pulmonary embolism", "options": {"A": "Pulmonary embolism", "B": "Cellulitis", "C": "Breast cancer", "D": "Hypercholesterolemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old woman", "physician", "routine bone mineral density screening", "not", "children", "Menopause", "age 55", "mother died of breast cancer", "age", "48 years", "hypertension", "takes ramipril", "Dual-energy x-ray absorptiometry", "femoral neck shows a score", "2 7 SD", "physician considers treatment", "raloxifene", "medication", "put", "increased risk", "following conditions"]}
{"question": "A multi-specialty physician practice is meeting to determine which compensation scheme would best serve the practice and its patient population. Which of the following are true in regards to physician compensation?", "answer": "Fee-for-service may incentivize physicians to increase healthcare utilization irrespective of quality", "options": {"A": "Capitation poses the least financial risk to physicians", "B": "Fee-for-service pays physicians a set amount of money per unit time for every patient under their care", "C": "Fee-for-service may incentivize physicians to increase healthcare utilization irrespective of quality", "D": "Fee-for-service poses the most amount of financial risk to physicians"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["multi specialty physician practice", "meeting to", "compensation scheme", "best", "practice", "patient population", "following", "true", "physician compensation"]}
{"question": "A 29-year-old woman presents to her primary care doctor for a prenatal visit. She has just learned that she is pregnant and estimates she is approximately 6 weeks pregnant given the timing of her last menstrual cycle. She has a history of recurrent fetal loss. In total, she has had 4 miscarriages between the gestational ages of 8 and 15 weeks. She has a history of systemic lupus erythematosus and has had several DVTs in the past and a clot in her lung once. Her vitals today are unremarkable. She is asking if there are any treatments she should receive to prevent fetal loss. Which of the following is the most appropriate management of this patient?", "answer": "Aspirin and heparin", "options": {"A": "Aspirin and heparin", "B": "Aspirin and warfarin", "C": "No treatment indicated", "D": "Rivaroxaban"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["29 year old woman presents", "primary care doctor", "prenatal visit", "learned", "pregnant", "estimates", "approximately", "weeks pregnant", "timing", "menstrual cycle", "history of recurrent fetal loss", "total", "4 miscarriages", "gestational ages", "8", "weeks", "history of systemic lupus erythematosus", "several DVTs", "past", "clot", "lung", "today", "unremarkable", "treatments", "receive to prevent fetal loss", "following", "most appropriate management", "patient"]}
{"question": "A 17-year-old girl is brought to the physician because she has not attained menarche. There is no personal or family history of serious illness. She is 168 cm (5 ft 5 in) tall and weighs 63 kg (139 lb); BMI is 22.3 kg/m2. Examination shows normal breast development. Scant axillary hair is present. Abdominal examination shows a firm, nontender left inguinal mass. Pelvic examination shows a blind vaginal pouch. Ultrasonography does not show a uterus or ovaries. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Androgen insensitivity", "options": {"A": "5-α reductase deficiency", "B": "Sex chromosome mosaicism", "C": "Sex chromosome monosomy", "D": "Androgen insensitivity"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "brought", "physician", "not", "menarche", "personal", "family history", "serious illness", "5 ft 5", "tall", "63 kg", "BMI", "kg/m2", "Examination shows normal breast development", "Scant axillary hair", "present", "Abdominal examination shows", "firm", "nontender left inguinal mass", "Pelvic examination shows", "blind vaginal pouch", "Ultrasonography", "not show", "uterus", "ovaries", "following", "most likely underlying cause", "patient's symptoms"]}
{"question": "A 68-year-old man presents with a 6-month history of worsening fatigue and weight loss. He is especially concerned about a recent episode in which he noticed a blurring of his vision and headache; he also notes that his “memory is not as good as it used to be,” which his wife confirms. Physical exam is notable only for pallor and general weakness. Laboratory studies reveal anemia as well as an elevated erythrocyte sedimentation rate. Serum protein electrophoresis (SPEP) reveals a sharp, narrow spike of monoclonal IgM; serum IgM concentration is 6.3 g/dL. What is the most likely diagnosis in this case?", "answer": "Waldenstrom’s macroglobulinemia", "options": {"A": "IgM monoclonal gammopathy of undetermined significance (MGUS)", "B": "Multiple myeloma", "C": "Waldenstrom’s macroglobulinemia", "D": "Non-Hodgkin’s lymphoma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["68 year old man presents", "month history", "worsening fatigue", "weight loss", "concerned", "recent episode", "blurring of", "vision", "headache", "notes", "memory", "not as good", "used to", "wife confirms", "Physical exam", "notable only", "pallor", "general weakness", "Laboratory studies reveal anemia", "elevated erythrocyte sedimentation rate", "Serum protein electrophoresis", "reveals", "sharp", "narrow spike", "monoclonal IgM", "serum IgM concentration", "6.3 g/dL", "most diagnosis", "case"]}
{"question": "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?", "answer": "Hyperphosphorylated tau", "options": {"A": "Alpha-synuclein", "B": "Amyloid-β", "C": "Hyperphosphorylated tau", "D": "Prion protein"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "brought", "physician", "daughter", "evaluation", "impaired", "word finding difficulties", "years", "recently", "to step down", "position", "volunteer accountant", "local charity organization", "longer able to coordinate", "tasks", "reports", "unable", "taste", "smell", "food", "Two years later", "patient", "autopsy", "examination", "brain shows generalized cortical atrophy", "photomicrograph", "section", "brain", "shown", "inclusions indicated", "arrows", "following substances"]}
{"question": "A 27-year-old man presents to the emergency department due to a change in his skin color. The patient went on a long hike this morning, and his girlfriend noticed that his skin had changed color when they were driving home. The patient has a past medical history of marijuana use, IV drug use, alcohol use, and asthma. His current medications include albuterol, fluticasone, and ibuprofen. His temperature is 97.5°F (36.4°C), blood pressure is 120/75 mmHg, pulse is 60/min, respirations are 10/min, and oxygen saturation is 98% on room air. Laboratory studies are ordered and are seen below.\n\nHemoglobin: 10 g/dL\nHematocrit: 32%\nLeukocyte count: 5,500 cells/mm^3 with normal differential\nPlatelet count: 207,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 99 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 24 mEq/L\nBUN: 17 mg/dL\nGlucose: 89 mg/dL\nCreatinine: 1.0 mg/dL\nCa2+: 10.1 mg/dL\nBilirubin, total: 11.3 mg/dL\nBilirubin, direct: 7.8 mg/dL\n\nPhysical exam is notable for a patient with skin that appears yellow/orange. Cardiac, pulmonary, abdominal, and neurological exams are within normal limits. Which of the following is associated with this patient's underlying pathology?", "answer": "Hyperpigmentation of the liver", "options": {"A": "A pathology responsive to sofosbuvir", "B": "Decreased UDP-glucuronyl transferase activity", "C": "Hyperpigmentation of the liver", "D": "Increased consumption of beta-carotene"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old man presents", "emergency department due", "change in", "skin color", "patient", "long", "morning", "girlfriend", "skin", "changed color", "driving home", "patient", "past medical history of marijuana use", "IV drug use", "alcohol use", "asthma", "current medications include albuterol", "fluticasone", "ibuprofen", "temperature", "97", "36 4C", "blood pressure", "75 mmHg", "pulse", "60 min", "respirations", "10/min", "oxygen saturation", "98", "room air", "Laboratory studies", "ordered", "seen", "Hemoglobin", "10 g/dL Hematocrit", "Leukocyte count", "5 500 cells mm", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "99 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "mg/dL Glucose", "mg/dL Creatinine", "1 0 mg/dL Ca2", "10", "mg/dL Bilirubin", "total", "mg/dL Bilirubin", "direct", "mg/dL", "Physical exam", "notable", "patient", "skin", "appears yellow orange", "Cardiac", "pulmonary", "abdominal", "neurological exams", "normal limits", "following", "associated with", "patient's", "pathology"]}
{"question": "A 40-year-old woman presents to the emergency department with severe left upper quadrant pain (duration 3 hours, stabbing quality, 10/10 on the pain scale). Past medical history is significant for sickle cell anemia. Physical examination is significant for severe tenderness to palpation in the left upper quadrant. Significant splenomegaly is also noted. The patient is admitted to the hospital for close observation and placed on deep vein thrombosis (DVT) prophylaxis as part of a routine protocol. Laboratory findings drawn sometime after admission demonstrate a normal prothrombin time (PT) and elevated partial thromboplastin time (PTT). Which of the following factors is most directly affected by the DVT prophylaxis?", "answer": "X", "options": {"A": "VII", "B": "VIIa", "C": "X", "D": "XII"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old woman presents", "emergency department", "severe left upper quadrant pain", "duration", "hours", "stabbing quality", "10", "pain scale", "Past medical history", "significant", "sickle cell anemia", "Physical examination", "significant", "severe tenderness", "palpation", "left upper quadrant", "Significant splenomegaly", "noted", "patient", "admitted", "hospital", "close observation", "placed", "deep vein thrombosis", "prophylaxis", "part of", "routine protocol", "Laboratory findings drawn", "admission", "normal prothrombin time", "elevated partial thromboplastin time", "following factors", "most directly affected", "DVT prophylaxis"]}
{"question": "A 47-year-old man with a history of HIV1 infection presents to his HIV clinic to discuss his antiretroviral medications. He is interested in including maraviroc in his maintenance regimen after seeing advertisements about the medication. On exam, his temperature is 98.8°F (37.1°C), blood pressure is 116/74 mmHg, pulse is 64/min, and respirations are 12/min. His viral load is undetectable on his current regimen, and his blood count, electrolytes, and liver function tests have all been within normal limits. In order to consider maraviroc for therapy, a tropism assay needs to be performed. Which of the following receptors is affected by the use of maraviroc?", "answer": "gp120", "options": {"A": "gp120", "B": "gp160", "C": "p24", "D": "Reverse transcriptase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "history", "HIV1 infection presents", "HIV clinic to discuss", "antiretroviral medications", "interested", "including maraviroc", "maintenance regimen", "seeing advertisements", "medication", "exam", "temperature", "98", "blood pressure", "74 mmHg", "pulse", "64 min", "respirations", "min", "viral load", "undetectable", "current regimen", "blood count", "electrolytes", "liver function tests", "normal limits", "order to consider maraviroc", "therapy", "tropism assay needs to", "performed", "following receptors", "affected", "use of maraviroc"]}
{"question": "A 16-year-old female presents to her physician’s office after noticing a round lump in her left breast 2 months ago. She reports that the lump seemed to enlarge and became tender just preceding her last 2 menses. It is otherwise painless, and the patient denies any discharge or skin changes. She has no past medical history but her grandmother, age 72, was just diagnosed with invasive ductal carcinoma of the breast. The patient is an avid softball player at her high school and denies alcohol, smoking, or illicit drug use. On exam, the breasts appear symmetric and normal. A 3-cm round, mobile mass is palpated in the upper outer quadrant of the left breast. There is slight tenderness to deep palpation of the mass. There is no axillary lymphadenopathy on either side. Which of the following is the most likely outcome of this patient’s condition?", "answer": "This mass will most likely decrease in size or disappear over time", "options": {"A": "This mass will decrease in size if the patient starts oral contraceptives", "B": "This mass slightly increases this patient’s risk of breast cancer in the future", "C": "This mass will most likely decrease in size or disappear over time", "D": "If this mass grows rapidly to greater than 5 cm, radiation and chemotherapy are indicated"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female presents", "physicians office", "round lump in", "left breast", "months", "reports", "lump", "to", "tender", "preceding", "last", "menses", "painless", "patient denies", "discharge", "skin changes", "past medical history", "grandmother", "age 72", "diagnosed", "invasive ductal carcinoma of the breast", "patient", "avid softball", "high school", "denies alcohol", "smoking", "illicit drug use", "exam", "breasts appear symmetric", "normal", "3", "round", "mobile mass", "palpated", "upper outer quadrant of", "left breast", "slight tenderness", "deep palpation", "mass", "axillary lymphadenopathy", "side", "following", "most likely outcome", "patients condition"]}
{"question": "A 22-year-old woman presents to the emergency department with a headache. She has had episodic headaches like this in the past and states that her headache today is severe, worse when laying down, and not responding to ibuprofen. She also reports a transient episode of vision loss and current blurry vision. She states she has a ringing in her ears as well. The patient has a past medical history of headaches, obesity, polycystic ovarian syndrome, and constipation. Her temperature is 98.7°F (37.1°C), blood pressure is 149/92 mmHg, pulse is 83/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is not remarkable and an initial head CT is within normal limits. Which of the following is the best next step in management for the most likely diagnosis?", "answer": "Lumbar puncture", "options": {"A": "Ibuprofen", "B": "Lumbar puncture", "C": "MRI", "D": "Tissue plasminogen activator"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "headache", "episodic headaches", "past", "states", "headache today", "severe", "worse", "laying", "not", "ibuprofen", "reports", "transient episode of vision loss", "current blurry vision", "states", "ringing in", "ears", "well", "patient", "past medical headaches", "obesity", "polycystic ovarian syndrome", "constipation", "temperature", "98", "blood pressure", "mmHg", "pulse", "83 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "not", "initial head CT", "normal limits", "following", "best next step", "management", "likely diagnosis"]}
{"question": "A 28-year-old woman presents to her primary care physician for evaluation of amenorrhea. Her last period occurred 4 months ago but she has not had sex in the last year and home pregnancy tests have come back negative. She first started having periods at age 13 and her periods have been unremarkable up until they stopped 4 months ago. Her past medical history is significant for radius and ulnar forearm fractures that she sustained in a car crash 3 months ago. She didn't see the car coming and has had increasing difficulty noticing objects in her peripheral vision. She also notes having recurrent headaches 5 months ago. Otherwise she has been healthy with no previous pregnancies. Physical exam reveals galactorrhea and temporal field visual defects. Which of the following mechanisms is most likely responsible for this patient's amenorrhea?", "answer": "Inhibition of gonadotropin-releasing hormone release", "options": {"A": "Inhibition of gonadotropin-releasing hormone release", "B": "Intrauterine scar tissue accumulation", "C": "Nondisjunction of chromosomes", "D": "Nutritional imbalance"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "evaluation", "amenorrhea", "last period occurred 4 months", "not", "sex", "year", "home pregnancy tests", "back negative", "first started", "periods", "age", "periods", "unremarkable", "stopped 4 months", "past medical history", "significant", "radius", "ulnar forearm fractures", "sustained", "car crash", "months", "see", "car", "increasing difficulty", "objects", "peripheral vision", "notes", "recurrent headaches", "months", "healthy", "previous pregnancies", "Physical exam reveals galactorrhea", "temporal field visual defects", "following mechanisms", "most likely responsible", "patient's amenorrhea"]}
{"question": "A 57-year-old homeless man is brought to the emergency department because of several episodes of hematemesis in the past 24 hours. His vital signs include a temperature of 37.1°C (98.8°F), pulse of 95/min, and blood pressure of 85/60 mm Hg. On physical examination, he appears confused and unable to give a complete history. He is noted to have jaundice, palpable firm liver, mild splenomegaly, and shifting dullness consistent with the presence of ascites. Liver function tests are as follows:\nSerum aspartate aminotransferase (AST)  97 U/L\nSerum alanine aminotransferase (ALT) 40 U/L\nSerum albumin 2.5 g/dL\nTotal bilirubin 3 mg/dL\nProthrombin time 20 seconds\nWhich of the following is the most likely cause of this patient's illness?", "answer": "Substance abuse", "options": {"A": "Metabolic disorder", "B": "Substance abuse", "C": "Obesity", "D": " Hepatic venous outflow obstruction"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["57 year old homeless man", "brought", "emergency department", "of several episodes", "hematemesis", "past 24 hours", "vital signs include", "temperature", "98", "pulse", "95 min", "blood pressure", "85 60 mm Hg", "physical examination", "appears confused", "unable to give", "complete history", "noted to", "jaundice", "palpable firm liver", "mild splenomegaly", "shifting dullness consistent", "presence of ascites", "Liver function tests", "follows", "Serum aspartate aminotransferase", "AST", "97 U/L Serum alanine aminotransferase", "ALT", "40 U/L Serum albumin", "g dL Total bilirubin", "mg dL Prothrombin time", "seconds", "following", "most likely cause", "patient's illness"]}
{"question": "A 66-year-old man presents to the emergency department for a cough and fatigue. The patient was brought in from a nursing home with documentation stating that he has seemed confused for the past day according to the staff. The patient has a past medical history of diabetes and hypertension. He is currently taking insulin, metformin, lisinopril, and atorvastatin. His temperature is 102°F (38.9°C), blood pressure is 107/58 mmHg, pulse is 120/min, respirations are 15/min, and oxygen saturation is 98% on room air. Physical exam reveals crackles on pulmonary exam and S4 on cardiac auscultation. Which of the following is the next best step in management?", "answer": "Moxifloxacin and admission to the medical floor", "options": {"A": "Azithromycin and admission to the medical floor", "B": "Azithromycin and discharge", "C": "Azithromycin, moxifloxacin, and admission to the intensive care unit", "D": "Moxifloxacin and admission to the medical floor"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["66 year old man presents", "emergency department", "cough", "fatigue", "patient", "brought", "nursing", "documentation stating", "confused", "past day", "staff", "patient", "past medical diabetes", "hypertension", "currently taking insulin", "metformin", "lisinopril", "atorvastatin", "temperature", "blood pressure", "58 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam reveals crackles", "pulmonary exam", "S4", "cardiac auscultation", "following", "next best step", "management"]}
{"question": "A 72-year-old man in a nursing home was brought to the emergency department with right hand and leg weakness for 1 hour. There has been a gradual increase in the degree of weakness. The patient is disoriented. The medical history includes ischemic heart disease diagnosed 2 months ago, and long histories of diabetes and hypertension (30 and 25 years, respectively). On examination, the reflexes are hypertonic and the Babinski reflex is positive. The CT scan is shown. What is the most likely pathologic change?", "answer": "Liquefactive necrosis", "options": {"A": "Gangrenous necrosis", "B": "Liquefactive necrosis", "C": "Caseous necrosis", "D": "Fibrinoid necrosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old man", "nursing home", "brought", "emergency department", "right hand", "leg weakness", "hour", "gradual increase", "degree", "weakness", "patient", "disoriented", "medical history includes ischemic heart disease diagnosed 2 months", "long histories", "diabetes", "hypertension", "30", "years", "examination", "reflexes", "Babinski reflex", "positive", "CT scan", "shown", "most likely pathologic change"]}
{"question": "An 11-year-old boy was brought in by his mother with red tender bumps on his legs. The patient’s mother says that his symptoms started 3 days ago with a low-grade fever, malaise, and joint pain. He began to improve over the next 2 days, but this morning, when he woke up, she noticed multiple painful red bumps on his shins. Past medical history is significant for a recent severe sore throat and fever 1 week ago which resolved without treatment. The vital signs include: temperature 38.0°C (100.4°F), blood pressure 120/70 mm Hg, pulse 85/min, and respiratory rate 15/min. Physical examination reveals multiple, firm and tender erythematous nodules with indistinct borders, averaging 4 cm in diameter. Lesions are localized to the anterior surface of the lower legs. No evidence of drainage, bleeding, abscess formation or ulceration. Which of the following is the next best diagnostic step in this patient?", "answer": "Throat culture", "options": {"A": "Throat culture", "B": "Chest radiograph", "C": "Bone marrow biopsy", "D": "Colonoscopy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "mother", "red tender", "legs", "patients mother", "symptoms started 3 days", "low-grade fever", "malaise", "joint pain", "began to", "next 2 days", "morning", "woke up", "multiple painful red", "shins", "Past medical history", "significant", "recent severe sore throat", "fever", "week", "resolved", "treatment", "vital signs include", "temperature", "100 4F", "blood pressure", "70 mm Hg", "pulse 85 min", "respiratory rate", "min", "Physical examination reveals multiple", "firm", "tender erythematous nodules", "borders", "averaging 4", "diameter", "Lesions", "localized", "anterior surface of", "lower legs", "evidence", "drainage", "bleeding", "abscess formation", "ulceration", "following", "next best diagnostic step", "patient"]}
{"question": "Two hours after admission to the hospital for rupture of membranes, a 35-year-old woman, gravida 3, para 2, at 40 weeks’ gestation is evaluated for the sudden onset of chills, dyspnea, confusion, and hypotension. The patient successfully underwent combined spinal-epidural anesthesia 1 hour ago. Her pregnancy was uncomplicated with the exception of a positive vaginal swab for group B streptococci 3 weeks ago, for which she received one dose of intravenous penicillin. Her temperature is 37.6°C (99.8°F), pulse is 130/min, respirations are 30/min, and blood pressure is 70/30 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 82%. Physical examination shows labored breathing and thready pulses. Crackles are heard at both lung bases. The abdomen is nontender. Speculum examination shows pooling of bright red blood in the cervical canal. Laboratory studies show a hemoglobin concentration of 7.6 mg/dL and an undetectable fibrinogen concentration. Which of the following is the most likely underlying cause of this patient’s current condition?", "answer": "Amniotic fluid entering the endocervical veins", "options": {"A": "Apical ballooning of the left ventricle", "B": "Amniotic fluid entering the endocervical veins", "C": "Anesthetic agent entering the subarachnoid space", "D": "Systemic bacterial infection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["Two hours", "admission", "hospital", "rupture of membranes", "35 year old woman", "gravida 3", "para 2", "40 weeks gestation", "evaluated", "sudden onset", "chills", "dyspnea", "confusion", "hypotension", "patient", "combined spinal epidural", "hour", "pregnancy", "uncomplicated", "exception", "positive vaginal swab", "group B streptococci", "weeks", "received one dose", "intravenous penicillin", "temperature", "99", "pulse", "min", "respirations", "30/min", "blood pressure", "70 30 mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "Physical examination shows labored breathing", "thready pulses", "Crackles", "heard", "lung bases", "abdomen", "nontender", "Speculum examination shows pooling", "bright red blood", "cervical canal", "Laboratory studies show", "hemoglobin concentration", "mg/dL", "undetectable fibrinogen concentration", "following", "most likely underlying cause", "patients current condition"]}
{"question": "A 54-year-old male presents to his primary care physician complaining of fatigue. He reports that he recently went on a vacation to South America with his family but just wanted to stay in his hotel all day due to fatigue. His past medical history is notable for hyperlipidemia and hypertension. He takes lovastatin and lisinopril. He drinks socially and has a 20 pack-year smoking history. His temperature is 99°F (37.2°C), blood pressure is 130/75 mmHg, pulse is 80/min, and respirations are 16/min. On exam, the patient is appropriately interactive and in no acute distress. Mild splenomegaly is noted. Laboratory analysis reveals the following:\n\nHemoglobin: 11.0 g/dL\nHematocrit: 36%\nLeukocyte count: 3,800/mm^3 with normal differential\nPlatelet count: 140,000/mm^3\n\nA bone marrow aspiration is ordered but after multiple attempts, they are unable to obtain an adequate bone marrow sample. A peripheral blood smear would likely reveal cells that stain with which of the following stains?", "answer": "Tartrate-resistant acid phosphatase", "options": {"A": "Prussian Blue", "B": "Ziehl-Neelsen", "C": "Periodic acid-Schiff", "D": "Tartrate-resistant acid phosphatase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["54 year old male presents", "primary care physician", "fatigue", "reports", "recently", "vacation", "South America", "family", "wanted to", "hotel all day due to fatigue", "past medical history", "notable", "hyperlipidemia", "hypertension", "takes lovastatin", "lisinopril", "drinks", "20 smoking history", "temperature", "blood pressure", "75 mmHg", "pulse", "80 min", "respirations", "min", "exam", "patient", "interactive", "acute distress", "Mild splenomegaly", "noted", "Laboratory analysis reveals", "following", "Hemoglobin", "0 g/dL Hematocrit", "36", "Leukocyte count", "3 800 mm 3", "normal differential Platelet count", "mm", "bone marrow aspiration", "ordered", "multiple attempts", "unable to obtain", "adequate bone marrow sample", "peripheral blood smear", "likely reveal cells", "stain", "following stains"]}
{"question": "While on a teaching sabbatical in Uruguay, a pathologist examined the excised liver of an 18-year-old otherwise healthy female who passed away due to massive hepatic necrosis 5 days after she underwent general anesthesia to repair a fractured femur. Which of the following is a general anesthetic most likely responsible for her death?", "answer": "Halothane", "options": {"A": "Lidocaine", "B": "Midazolam", "C": "Halothane", "D": "Desflurane"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["teaching", "Uruguay", "pathologist examined", "liver", "year old", "healthy female", "passed", "due to massive hepatic necrosis 5 days", "general anesthesia to repair", "fractured femur", "following", "general", "likely responsible", "death"]}
{"question": "A 45-year-old woman with hypothyroidism comes to the physician because of progressive fatigue, lethargy, and epigastric pain after eating. Physical examination shows pale conjunctivae. Laboratory studies show decreased serum hemoglobin levels and increased serum gastrin levels. Esophagogastroduodenoscopy shows inflammation of the gastric body and fundus. A photomicrograph of a biopsy specimen taken from the gastric antrum is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Parietal cell destruction", "options": {"A": "Mucosal cell hyperplasia", "B": "Enterochromaffin-like cell hyperplasia", "C": "Parietal cell destruction", "D": "Chief cell destruction"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "hypothyroidism", "physician", "progressive fatigue", "lethargy", "epigastric", "eating", "Physical examination shows pale conjunctivae", "Laboratory studies show decreased serum hemoglobin", "increased serum gastrin levels", "Esophagogastroduodenoscopy shows inflammation", "gastric", "fundus", "photomicrograph", "biopsy specimen taken", "gastric antrum", "shown", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 72-year-old anthropologist with long-standing hypertension visits your office for a routine exam. You notice an abnormality on his laboratory results caused by his regimen of captopril and triamterene. What abnormality did you most likely find?", "answer": "Hyperkalemia", "options": {"A": "Hyperkalemia", "B": "Hypernatremia", "C": "Thrombocytopenia", "D": "Anemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["72 year old anthropologist", "long standing hypertension visits", "office", "routine exam", "abnormality", "laboratory results caused", "regimen", "captopril", "triamterene", "abnormality", "most likely find"]}
{"question": "A 56-year-old woman is brought to the emergency department by her husband because of increasing confusion, generalized fatigue, and irritability for the past week. She has been unable to recall her husband's name or their address. She has had insomnia and daytime sleepiness during this period. Her last bowel movement was 3 days ago. One month ago, she underwent a transjugular intrahepatic portal shunt (TIPS) placement. She has alcoholic liver cirrhosis. Current medications include spironolactone and furosemide. She used to drink over a pint of vodka daily but quit 2 months ago. She is oriented to place and person. Her temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 102/64 mm Hg. Examination shows scleral icterus and jaundice. There are several telangiectasias over the chest and back. Palmar erythema is present. The abdomen is mildly distended and nontender. Shifting dullness is present. There is a flapping tremor of both hands when outstretched and dorsiflexed. Neurologic examination shows no other focal findings. She completes the number connection test slower than the age-normalized standard. Which of the following is the most appropriate next step in management?", "answer": "Administer lactulose", "options": {"A": "Reversal of TIPS", "B": "Paracentesis", "C": "Administer IV ceftriaxone", "D": "Administer lactulose"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "husband", "increasing confusion", "generalized fatigue", "irritability", "past week", "unable to recall", "husband's name", "address", "insomnia", "daytime sleepiness", "period", "last bowel movement", "3 days", "One month", "transjugular intrahepatic portal shunt", "placement", "alcoholic liver cirrhosis", "Current medications include spironolactone", "furosemide", "used to drink", "pint", "vodka daily", "quit", "months", "oriented to place", "person", "temperature", "3C", "99", "pulse", "88 min", "blood pressure", "64 mm Hg", "Examination shows scleral icterus", "jaundice", "several telangiectasias", "chest", "back", "Palmar erythema", "present", "abdomen", "mildly distended", "nontender", "Shifting dullness", "present", "flapping tremor of", "hands", "dorsiflexed", "Neurologic examination shows", "focal findings", "completes", "number connection test slower", "age normalized standard", "following", "most appropriate next step", "management"]}
{"question": "A 50-year-old woman is brought to the office by her daughter with a chief complaint of finger pain in her left hand. She is slightly confused and can’t remember when the pain started. Her daughter states that the pain has been present for approximately one month. She expresses concern that her mother has been progressively more confused during the past week. She reports that her mother also has had worsening nausea for several months. The patient’s vital signs are heart rate 92/min, respiratory rate 13/min, temperature 37.1°C (98.8°F), and blood pressure 120/86 mm Hg. Upon physical examination, the patient reports pain when the fingers of the left hand are palpated, and small palpable tumors are visible on the fingers. An X-ray image of the left-hand shows thin bones with brown tumors and osteolysis of the distal phalanges. What is the most likely cause for this patient’s condition?", "answer": "Hyperparathyroidism", "options": {"A": "Hyperparathyroidism", "B": "Hypocalcemia", "C": "Osteosarcoma", "D": "Multiple myeloma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["50 year old woman", "brought", "office", "daughter", "chief complaint of finger pain", "left hand", "slightly confused", "cant remember", "pain started", "daughter states", "pain", "present", "approximately one month", "concern", "mother", "more confused", "past week", "reports", "mother", "worsening nausea", "months", "patients vital signs", "heart rate", "min", "respiratory rate", "min", "temperature", "98", "blood pressure", "mm Hg", "physical examination", "patient reports pain", "fingers of", "left hand", "palpated", "small palpable tumors", "visible", "fingers", "X-ray image", "left-hand shows thin bones", "brown tumors", "osteolysis of", "distal phalanges", "most likely cause", "patients condition"]}
{"question": "A 48-year-old woman comes to the physician because of a 4-month history of lightheadedness, intermittent headaches, and easy bruising. Five months ago, she was treated for an episode of thrombophlebitis. Physical examination shows multiple bruises on her limbs. Laboratory studies show a platelet count of 900,000/mm3 and elevated levels of serum lactate dehydrogenase and uric acid. Treatment with a medication is begun that is also used in the treatment of sickle cell disease. Which of the following mechanisms is most likely responsible for the beneficial effect of this drug in sickle cell disease?", "answer": "Increase in circulating fetal hemoglobin", "options": {"A": "Inhibition of thrombocyte aggregation", "B": "Increase in circulating fetal hemoglobin", "C": "Inhibition of stem cell differentiation", "D": "Restoration of the body's iron stores"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["48 year old woman", "physician", "4 month history", "lightheadedness", "intermittent headaches", "easy bruising", "Five months", "treated", "episode of thrombophlebitis", "Physical examination shows multiple bruises", "limbs", "Laboratory studies show", "platelet count", "900", "mm3", "elevated levels", "serum lactate dehydrogenase", "uric acid", "Treatment with", "medication", "begun", "used", "treatment of sickle cell disease", "following mechanisms", "most likely responsible", "beneficial effect", "drug", "sickle cell disease"]}
{"question": "Candida is injected into the skin of a 38-year-old female patient. Forty-eight hours later, there is a 14 mm raised, slightly hardened area at the injection site. What type of hypersensitivity reaction has occurred and what cell type plays a role?", "answer": "Type IV hypersensitivity; CD4+ T cells", "options": {"A": "Type I hypersensitivty; eosinophils", "B": "Type IV hypersensitivity; mast cells", "C": "Type III hypersensitivity; CD4+ T cells", "D": "Type IV hypersensitivity; CD4+ T cells"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Candida", "injected", "skin", "year old female patient", "Forty-eight hours later", "mm raised", "slightly hardened area", "injection site", "type", "hypersensitivity", "occurred", "cell type plays", "role"]}
{"question": "On routine screening, a 62-year-old man is found to have positive fecal occult blood tests. He is asymptomatic, but his father died of large intestinal cancer. Abdominal and rectal exams are normal. A colonoscopy subsequently reveals a polyp in the descending colon but no other abnormalities. Excisional biopsy of the polyp shows 75% tubular architecture. Which of the following is the most likely diagnosis?", "answer": "Adenomatous polyp", "options": {"A": "Inflammatory polyp", "B": "Adenomatous polyp", "C": "Hamartomatous polyp", "D": "Colorectal cancer"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["routine screening", "62 year old man", "found to", "positive fecal occult blood tests", "asymptomatic", "father died of large intestinal cancer", "Abdominal", "rectal exams", "normal", "colonoscopy", "reveals", "polyp", "descending colon", "abnormalities", "Excisional biopsy", "polyp shows 75", "tubular architecture", "following", "most likely diagnosis"]}
{"question": "A 20-year-old male college student presents to the emergency room at 4 AM in the morning with complaints of abdominal cramps, nausea, vomiting, and diarrhea for the past 2 hours. He was studying for his exams last night when he became hungry and ate some food from the afternoon after heating it for a while. He says that his symptoms began an hour after he ate the food. His temperature is 37°C (98.6°F), respiratory rate is 15/min, pulse is 106/min, and blood pressure is 90/78 mm Hg. A physical examination is within normal limits except for signs of dehydration. What is the most likely diagnosis?", "answer": "Bacillus cereus infection", "options": {"A": "Cryptosporidiosis", "B": "C. difficile colitis", "C": "Bacillus cereus infection", "D": "Norovirus infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["20 year old male college student presents", "emergency room", "4", "morning", "complaints", "abdominal cramps", "nausea", "vomiting", "diarrhea", "past", "hours", "studying", "exams last night", "hungry", "ate", "food", "afternoon", "heating", "symptoms began", "hour", "ate", "food", "temperature", "98", "respiratory rate", "min", "pulse", "min", "blood pressure", "90", "mm Hg", "physical examination", "normal limits except for signs", "dehydration", "most likely diagnosis"]}
{"question": "A 79-year-old woman presents to her physician complaining of a persistent non-productive cough and dyspnea after contracting a cold in the past month. She describes herself as being “generally healthy” before the cold started. Medical history includes hypertension and hyperlipidemia. The patient takes hydrochlorothiazide, lisinopril, and atorvastatin. Her parents are both deceased. She does not smoke and only drinks alcohol occasionally. During a review of symptoms, she described a month-long trip to St. Louis, Missouri, to visit family. At the physician’s office, her temperature is 37.0°C (98.6°F), pulse is 82/min, respirations are 20/min, and blood pressure is 130/82 mm Hg. A focused chest exam reveals mild crepitus on the right side. A chest X-ray shows a cavitary lesion in the right lung which is confirmed on chest computed tomography (CT). A lung biopsy is performed to rule out cancer and reveals necrotic granulomatous inflammation with oval yeast in macrophages. Which of the following is the most likely diagnosis?", "answer": "Histoplasmosis", "options": {"A": "Blastomycosis", "B": "Sporotrichosis", "C": "Histoplasmosis", "D": "Onychomycosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "physician", "persistent non-productive cough", "dyspnea", "contracting", "cold", "past month", "healthy", "cold started", "Medical history includes hypertension", "hyperlipidemia", "patient takes hydrochlorothiazide", "lisinopril", "atorvastatin", "parents", "deceased", "not smoke", "only drinks alcohol occasionally", "review", "symptoms", "described", "month long trip", "St", "Missouri", "to visit family", "physicians office", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "mm Hg", "focused chest exam reveals mild crepitus", "right side", "chest X-ray shows", "cavitary lesion", "right lung", "confirmed", "chest computed tomography", "lung biopsy", "performed to rule out cancer", "reveals necrotic granulomatous inflammation with oval yeast", "macrophages", "following", "most likely diagnosis"]}
{"question": "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?", "answer": "Pregnancy success rate with donor oocytes is similar to patients with primary ovarian failure", "options": {"A": "Pregnancy success rate with donor oocytes is similar to patients with primary ovarian failure", "B": "Administration of gonadotropins will increase the chances of conceiving", "C": "Impaired tubal ciliary function will prevent natural fertilization", "D": "The majority of patients become pregnant without medical assistance"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "physician", "not", "period", "percentile", "height", "percentile", "weight", "Examination shows", "broad chest", "widely spaced nipples", "low posterior hairline", "forearms angled 20", "body", "extended", "shortened fourth metacarpals", "Sexual development", "Tanner", "following statements", "patient's fertility", "most accurate"]}
{"question": "An investigator is studying traumatic knee joint injuries in college athletes. Images and tissue samples are collected from 4 athletes with cartilaginous injury and 4 athletes with bone fractures. After 8 weeks, the athletes with bone fractures show almost complete resolution, while the athletes with cartilaginous injuries show only minimal signs of healing. The investigator hypothesizes that this is due to the absence of progenitor cells for matrix regeneration. Transplant of which of the following tissues would most likely promote healing in the group with cartilaginous injury?", "answer": "Perichondrium", "options": {"A": "Perichondrium", "B": "Proteoglycans", "C": "Osteoblasts", "D": "Mature chondrocytes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying traumatic knee joint injuries", "college athletes", "Images", "tissue samples", "collected", "athletes", "cartilaginous injury", "4 athletes", "bone fractures", "weeks", "athletes", "bone fractures show almost complete resolution", "athletes", "cartilaginous injuries show only minimal signs", "healing", "investigator", "due to", "absence", "progenitor cells", "matrix regeneration", "Transplant", "following tissues", "most likely promote healing", "group", "cartilaginous injury"]}
{"question": "A 35-year-old woman comes to the physician for the evaluation of increasing weakness and numbness of the upper extremities for 5 days. During the past 2 days, she has had urinary incontinence not related to sneezing or laughing. Last summer, she had weakness and numbness of her right lower extremity that was worse when she was outside; she regained her strength 3 weeks later. She has no history of serious illness. She has had 10 male sexual partners in her lifetime and uses condoms inconsistently. Vital signs are within normal limits. Examination shows an impaired tandem gait. There is mild spasticity and muscle strength is decreased in both upper extremities. Deep tendon reflexes are 4+ bilaterally. The abdominal reflex is absent. Muscle strength in the right lower extremity is mildly decreased. Sensation to vibration and fine touch is decreased over the upper extremities. Which of the following is the most appropriate next step in diagnosis?", "answer": "MRI of the brain and spine", "options": {"A": "Muscle biopsy", "B": "Rapid plasma reagin test", "C": "MRI of the brain and spine", "D": "Lumbar puncture"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old woman", "physician", "evaluation", "increasing weakness", "numbness", "upper extremities", "5 days", "past 2 days", "urinary incontinence not related", "sneezing", "laughing", "summer", "weakness", "numbness", "right", "worse", "outside", "regained", "strength", "weeks later", "history", "serious illness", "10 male sexual partners", "lifetime", "uses condoms", "Vital signs", "normal limits", "Examination shows", "impaired tandem gait", "mild spasticity", "muscle strength", "decreased", "upper extremities", "Deep tendon reflexes", "4", "abdominal reflex", "absent", "Muscle", "right lower extremity", "mildly decreased", "Sensation", "vibration", "fine touch", "decreased", "upper extremities", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 37-year-old woman presents to your office with heartburn. Following an extensive workup, you diagnose her with a duodenal ulcer secondary to H. pylori infection. You prescribe triple therapy of omeprazole, clarithromycin, and amoxicillin. Which of the following best describes the mechanism of action of omeprazole?", "answer": "Inhibition of primary active transport", "options": {"A": "Parasympathetic inhibition", "B": "Reversible block of H2 receptors", "C": "Inhibition of primary active transport", "D": "Inhibition of 50S ribosomal subunit"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "office", "heartburn", "Following", "extensive workup", "diagnose", "duodenal ulcer secondary to H", "pylori infection", "triple therapy", "omeprazole", "clarithromycin", "amoxicillin", "following best", "mechanism of action", "omeprazole"]}
{"question": "A 47-year-old woman comes to the emergency department because of worsening pain, discoloration, and swelling of her right hand. Two days ago, she was camping outdoors in Texas with her two young children. She was awoken in the middle of the night by “something crawling on my hand.” The following morning, she saw a wound on her hand that was initially painless, but over the next several hours she noticed reddening and blistering. Yesterday, the lesion turned blue with a blackish discoloration at the center. Her temperature is 38°C (100.4°F), pulse is 83/min, and blood pressure is 128/84 mm Hg. Physical examination shows a bluish plaque with a central area of necrosis surrounded by a rim of erythema at the dorsum of the right hand. Which of the following animals is most likely responsible for the patient's symptoms?", "answer": "Brown recluse spider", "options": {"A": "Diamondback rattlesnake", "B": "Brown recluse spider", "C": "Striped bark scorpion", "D": "Deer tick"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "emergency department", "worsening pain", "discoloration", "swelling of", "right hand", "Two days", "camping outdoors", "Texas", "two young children", "awoken", "middle", "night", "crawling", "hand", "following morning", "saw", "wound", "hand", "initially painless", "next", "hours", "blistering", "lesion turned blue", "discoloration", "center", "temperature", "100 4F", "pulse", "83 min", "blood pressure", "84 mm Hg", "Physical examination shows", "plaque", "central area", "necrosis surrounded", "rim", "erythema", "dorsum of", "right hand", "following animals", "most likely responsible", "patient's symptoms"]}
{"question": "Two weeks after starting chemotherapy with etoposide, a 66-year-old man with small cell lung cancer comes to the physician because of persistent nausea and vomiting. His symptoms improve significantly after the administration of metoclopramide. This patient's symptoms were most likely due to the effect of chemotherapy on which of the following structures?", "answer": "Area postrema", "options": {"A": "Vestibular nerve", "B": "Intestinal smooth muscle", "C": "Vagus nerve", "D": "Area postrema"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Two weeks", "starting chemotherapy", "etoposide", "66 year old man", "small cell lung cancer", "physician", "persistent nausea", "vomiting", "symptoms", "administration", "metoclopramide", "patient's symptoms", "most likely due to", "effect", "chemotherapy", "following structures"]}
{"question": "A 55-year-old construction worker is struck by a high-voltage power line while on duty. According to bystanders, the cable struck him on his right arm, after which the man slumped to the ground with his arms and legs shaking. In the emergency department, the man is alert but in severe pain localizing bilaterally in the flanks as well as in his right arm where contact with the power line occurred. A 6 cm burn is present on the right arm. His vitals are within normal limits except for mild tachypnea at 21/min. Which of the following diagnostic tests should be conducted first to evaluate this patient?", "answer": "Urinalysis", "options": {"A": "FAST ultrasound assessment", "B": "Urinalysis", "C": "X-ray of the arm and shoulder", "D": "EEG"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["55 year old construction worker", "struck by", "high voltage power line", "bystanders", "cable struck", "right arm", "man", "arms", "legs shaking", "emergency department", "man", "alert", "severe", "flanks as well", "right arm", "contact with", "power line occurred", "burn", "present", "right arm", "normal limits except for mild tachypnea", "min", "following diagnostic tests", "conducted first to evaluate", "patient"]}
{"question": "A 69-year-old male presents to the emergency department with shortness of breath. The patient has presented three times this past month with similar complaints. The patient sees no primary care physician and is currently not taking any medications. The patient states his shortness of breath started when he was walking from his car to a local restaurant. His temperature is 99.5°F (37.5°C), pulse is 100/min, blood pressure is 130/90 mmHg, respirations are 18/min, and oxygen saturation is 96% on room air. On physical exam you note a fatigued appearing gentleman. Cardiovascular exam reveals an additional heart sound after S2. Pulmonary exam is notable for bilateral crackles. Abdominal exam reveals an obese abdomen without pain in any of the quadrants. Lower extremity pitting edema is noted bilaterally. Which of the following sets of lab values most likely corresponds to this patient's presentation?", "answer": "High BNP, high ADH, low sodium, low potassium", "options": {"A": "High BNP, high ADH, high sodium, high potassium", "B": "High BNP, low ADH, normal sodium, low potassium", "C": "High BNP, high ADH, low sodium, low potassium", "D": "Low BNP, low ADH, normal sodium, normal potassium"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["69 year old male presents", "emergency department", "shortness of breath", "patient", "presented three times", "past month", "similar complaints", "patient sees", "primary care physician", "currently not taking", "medications", "patient states", "shortness of breath started", "walking", "car", "local restaurant", "temperature", "99", "pulse", "100 min", "blood pressure", "90 mmHg", "respirations", "min", "oxygen saturation", "96", "room air", "physical exam", "note", "fatigued appearing", "Cardiovascular exam reveals", "additional heart", "S2", "Pulmonary exam", "notable", "bilateral crackles", "Abdominal exam reveals", "obese", "pain", "quadrants", "Lower extremity pitting edema", "noted", "following sets", "lab values", "likely", "patient's presentation"]}
{"question": "A 48-year-old man presents to the clinic with nausea, vomiting, fever, and pain in the right upper quadrant of his abdomen for the past 18 hours. He mentions that he has been experiencing intermittent episodes of pain at the same location over the last 3 months and that these episodes usually occur after a heavy meal and subside within 1 or 2 hours. On physical examination, his temperature is 38.5°C (101.3°F), pulse is 130/min, respirations are 24/min, and blood pressure is 130/84 mm Hg. On examination of the abdomen, tenderness is present over the right upper quadrant; palpation over the area produces an inspiratory pause. An urgent bedside ultrasonogram shows a dilated common bile duct stone, but no stone in the common bile duct or in the gallbladder. Laboratory results show the following:\nHemoglobin 15.4 g/dL (9.56 mmol/L)\nTotal leukocyte count 14,000/mm3 (17.4 x 10*9/L)\nSegmented neutrophils 70%\nLymphocytes 25%\nMonocytes 4%\nEosinophils 1%\nBasophils 0%\nPlatelet count 32,0000/mm3 (320 x 10*9/L)\nSerum bilirubin (total) 1.8 mg/dL (30.78 μmol/L)\nSerum bilirubin (direct) 1.1 mg/dL (18.81 μmol/L)\nSerum alanine aminotransferase 96 U/L\nSerum aspartate aminotransferase 88 U/L\nSerum alkaline phosphatase\n350 U/L (5.83 μkat/L)\nWhich of the following is the most appropriate next step in management?", "answer": "Urgent endoscopic retrograde cholangiopancreatography (ECRP)", "options": {"A": "Urgent laparoscopic cholecystectomy", "B": "Medical management followed by elective laparoscopic cholecystectomy", "C": "Urgent endoscopic retrograde cholangiopancreatography (ECRP)", "D": "Cholecystotomy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["48 year old man presents", "clinic", "nausea", "vomiting", "fever", "pain", "right upper quadrant", "abdomen", "past 18 hours", "experiencing intermittent episodes of pain", "same location", "months", "episodes usually occur", "heavy meal", "2 hours", "physical examination", "temperature", "pulse", "min", "respirations", "min", "blood pressure", "84 mm Hg", "examination of", "abdomen", "tenderness", "present", "right upper quadrant", "palpation", "area", "inspiratory pause", "urgent", "ultrasonogram shows", "dilated common bile duct stone", "stone", "common bile duct", "gallbladder", "Laboratory results show", "following", "Hemoglobin 15.4 g", "mmol/L", "Total leukocyte count", "mm3", "10", "Segmented", "Lymphocytes", "Monocytes", "Eosinophils", "Basophils 0", "Platelet count 32", "mm3", "320", "10", "Serum bilirubin", "total", "1.8 mg/dL", "30", "mol/L", "Serum bilirubin", "direct", "1.1 mg/dL", "81 mol/L", "Serum alanine aminotransferase 96 U", "aspartate aminotransferase 88", "alkaline phosphatase 350", "5 83 kat/L", "following", "most appropriate next step", "management"]}
{"question": "A 22-year-old man is brought to the emergency department by police after he was found undressing himself outside in 110°F weather. The patient refuses to answer any questions as he suspects that his care team is spying on him. The patient recently started college and has presented to the emergency department once before for polysubstance intoxication. The patient attempts to assault a nurse, is restrained, and given diphenhydramine and haloperidol. When the patient is able to be examined, he is somnolent and non-responsive. His temperature is 104°F (40°C), blood pressure is 147/98 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. He does not comply with any commands, and it is not possible to freely manipulate his extremities due to rigidity. His mucous membranes are dry. Which of the following is the most likely diagnosis?", "answer": "Neuroleptic malignant syndrome", "options": {"A": "Catatonic schizophrenia", "B": "Heat stroke", "C": "Neuroleptic malignant syndrome", "D": "Oversedation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "emergency department", "police", "found undressing", "outside", "weather", "patient refuses to answer", "questions", "suspects", "care team", "patient recently started college", "presented", "emergency department", "before", "polysubstance intoxication", "patient attempts to assault", "nurse", "restrained", "given diphenhydramine", "haloperidol", "patient", "able to", "examined", "somnolent", "non responsive", "temperature", "blood pressure", "98 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "not comply", "commands", "not possible", "freely manipulate", "extremities due to rigidity", "mucous membranes", "dry", "following", "most likely diagnosis"]}
{"question": "A 32-year-old woman presents to the emergency department with abdominal pain and vaginal discharge. She gave birth to a healthy baby boy three days prior to presentation. Since then, she has been feeling sick, and she is concerned that she has been getting worse over time. On presentation, her temperature is 100.7°F (38.1°C), blood pressure is 115/78 mmHg, pulse is 105/min, and respirations are 14/min. Physical exam reveals abdominal discomfort with uterine tenderness, and laboratory results show elevated white blood cell count with many plasma cells. The most likely cause of this patient's disorder has which of the following characteristics?", "answer": "Beta-hemolytic cocci in chains", "options": {"A": "Alpha-hemolytic cocci in chains", "B": "Beta-hemolytic cocci in chains", "C": "Coagulase-positive cocci in clusters", "D": "Gamma-hemolytic cocci in chains"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "abdominal pain", "vaginal discharge", "gave birth", "healthy baby boy three days", "presentation", "then", "feeling sick", "concerned", "getting worse", "time", "presentation", "temperature", "100", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "Physical exam reveals abdominal discomfort", "uterine tenderness", "laboratory results show elevated white blood cell count", "most likely cause", "patient's", "following characteristics"]}
{"question": "An 18-month-old boy is brought to his pediatrician because his mother is concerned about his walking. The boy was born at 37 weeks’ gestation and spent 1 night in the neonatal intensive care unit for respiratory distress. He otherwise has been healthy and started walking independently at 12 months. However, his mother reports that he has stopped walking and appears weaker than he was a few months ago. He also has started having brief convulsive episodes over the past week. His parents are both healthy with no medical conditions. On exam, the child demonstrates muscle rigidity and diffuse muscle wasting. He is unable to stand or sit up straight. His patellar, Achilles, and brachioradialis reflexes are absent. Fundoscopic examination is unremarkable. A urine sample demonstrates metachromic granules. This patient’s condition is caused by a defect in which of the following enzymes?", "answer": "Arylsulfatase A", "options": {"A": "Alpha-galactosidase A", "B": "Arylsulfatase A", "C": "Beta-galactocerebrosidase", "D": "Hexosaminidase A"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "pediatrician", "mother", "concerned", "walking", "boy", "born", "weeks gestation", "spent 1 night", "neonatal intensive care unit", "respiratory distress", "healthy", "started walking", "12 months", "mother reports", "stopped walking", "appears weaker", "few months", "started", "brief convulsive episodes", "past week", "parents", "healthy", "medical conditions", "exam", "child demonstrates muscle rigidity", "diffuse muscle wasting", "unable to stand", "sit up straight", "patellar", "Achilles", "brachioradialis reflexes", "absent", "Fundoscopic examination", "unremarkable", "urine sample demonstrates", "granules", "patients condition", "caused", "defect", "following enzymes"]}
{"question": "A 45-year-old man presents to his primary care provider for two weeks of low-grade fever and sore throat. Upon further questioning, the patient is found to have unprotected sex with both men and women with 3-5 partners per month. On workup, he is found to have an HIV viral load of 15,000 copies/mL with a CD4+ of 170 cells/mm^3. He is started on medical therapy. What should be included in his medication regimen?", "answer": "Folinic acid", "options": {"A": "Azithromycin", "B": "Fluconazole", "C": "Folinic acid", "D": "Tetrahydrofolic acid"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "primary care provider", "two weeks", "low-grade fever", "sore throat", "further questioning", "patient", "found to", "unprotected sex", "men", "women", "partners", "month", "workup", "found to", "HIV viral load", "copies/mL", "CD4", "cells mm", "started", "medical therapy", "included", "medication regimen"]}
{"question": "A 71-year-old woman comes to the physician for evaluation of a pigmented lesion on her left foot. She has had decreased appetite and a 6-kg (13-lb) weight loss in the past 2 months. Physical examination shows that on the left medial ankle there is a 2-cm reddish-black nodule with a verrucous surface. A full-thickness excisional biopsy of the lesion shows S100-protein-positive epithelioid cells. A subsequent CT scan of the chest, abdomen, and pelvis shows metastases to the liver; a diagnosis of metastatic melanoma is made. Chemotherapy with aldesleukin is initiated. Which of the following is the mechanism of action for this drug?", "answer": "Activating natural killer cells and cytotoxic T cells", "options": {"A": "Stimulating release of acute-phase reactants", "B": "Stimulating antigen-processing cells", "C": "Activating natural killer cells and cytotoxic T cells", "D": "Supporting growth of bone marrow stem cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["71 year old woman", "physician", "evaluation", "pigmented lesion", "left foot", "decreased appetite", "kg", "weight loss", "past", "months", "Physical examination shows", "left medial ankle", "2", "black nodule", "verrucous surface", "full-thickness excisional", "lesion shows S100-protein positive epithelioid cells", "subsequent CT scan of", "chest", "abdomen", "pelvis shows metastases to the liver", "diagnosis", "metastatic melanoma", "made", "Chemotherapy", "aldesleukin", "initiated", "following", "mechanism of action", "drug"]}
{"question": "A 27-year-old female presents to her physician with a palpable thyroid nodule. Iodine uptake testing shows that the nodule has decreased iodine uptake compared with the rest of the thyroid gland. A fine-needle aspiration is performed and the physician calls telling the patient that she has a neoplasm of the thyroid. Which of the following diagnoses is the most likely?", "answer": "Papillary carcinoma", "options": {"A": "Papillary carcinoma", "B": "Medullary carcinoma", "C": "Follicular carcinoma", "D": "Anaplastic carcinoma"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["27 year old female presents", "physician", "palpable thyroid nodule", "Iodine uptake testing shows", "nodule", "decreased iodine uptake compared", "rest", "thyroid gland", "fine-needle aspiration", "performed", "physician calls", "patient", "neoplasm of the thyroid", "following diagnoses", "most likely"]}
{"question": "A 58-year-old male presents with an acutely elevated blood pressure of 220/140 mmHg. The patient complains of a headache and chest pain, and he has been vomiting for the last several hours. Physical exam demonstrates papilledema and a depressed level of consciousness. To treat this patient's hypertensive emergency, he is started on an IV medication commonly used in this situation. The agent exerts its effect by releasing nitric oxide as a metabolite, which subsequently activates guanylate cyclase and increases production of cGMP in vascular smooth muscle. Which of the following clinical effects would be expected from administration of this medication?", "answer": "Decreased pulmonary capillary wedge pressure", "options": {"A": "Decreased cardiac contractility", "B": "Increased left ventricular end-diastolic pressure", "C": "Decreased stroke volume", "D": "Decreased pulmonary capillary wedge pressure"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["58 year old male presents", "elevated blood pressure", "mmHg", "patient", "headache", "chest pain", "vomiting", "hours", "Physical exam demonstrates papilledema", "depressed level of consciousness", "To treat", "patient's hypertensive emergency", "started", "IV medication", "used", "agent exerts", "effect", "releasing nitric oxide", "metabolite", "activates guanylate cyclase", "increases production", "cGMP", "vascular smooth muscle", "following clinical effects", "expected", "administration of", "medication"]}
{"question": "A 24-year-old woman delivers a baby at term. The Apgar counts are 9 and 10 at 1 and 5 minutes, respectively. Thirty minutes after delivery, the mother’s blood pressure drops to 80/60 mm Hg and her pulse is 124/min. On physical examination, her distal extremities are clammy and cold, and the uterus is boggy. Aggressive fluid resuscitation is initiated. After administering 4 units of IV fluids and 4 units of whole blood, her vitals stabilize. The next morning, she says she is unable to lactate when she tries to breastfeed her child. Which of the following is the most likely cause of the failure of lactation in this patient?", "answer": "Pituitary infarction", "options": {"A": "Pituitary tumor", "B": "Remains of placenta in uterus", "C": "Pituitary infarction", "D": "Pituitary hemorrhage"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman delivers", "baby", "term", "Apgar counts", "10", "5 minutes", "Thirty minutes", "delivery", "mothers blood pressure drops", "80 60 mm Hg", "pulse", "min", "physical examination", "distal extremities", "clammy", "cold", "uterus", "boggy", "Aggressive fluid resuscitation", "initiated", "administering 4 units", "IV fluids", "4 units of whole blood", "stabilize", "next morning", "unable", "lactate", "to breastfeed", "child", "following", "most likely cause of", "failure", "lactation", "patient"]}
{"question": "A 3-year-old boy is brought to the physician because of a 3-day history of fatigue and yellow discoloration of his skin. One week ago, he had an upper respiratory tract infection. Examination shows jaundice of the skin and conjunctivae. The spleen tip is palpated 2 cm below the left costal margin. His hemoglobin concentration is 9.4 g/dl and his mean corpuscular hemoglobin concentration is 39% Hb/cell. A Coombs test is negative. A peripheral blood smear is shown. This patient is at greatest risk for which of the following complications?", "answer": "Cholecystitis", "options": {"A": "Acute myelogenous leukemia", "B": "Cholecystitis", "C": "Renal papillary necrosis", "D": "Splenic sequestration crisis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["3 year old boy", "brought", "physician", "3-day history", "fatigue", "yellow", "skin", "One week", "upper respiratory tract infection", "Examination shows jaundice", "skin", "conjunctivae", "spleen tip", "palpated 2 cm", "left costal margin", "hemoglobin concentration", "g/dl", "mean corpuscular hemoglobin concentration", "Hb cell", "Coombs test", "negative", "peripheral blood smear", "shown", "patient", "greatest risk", "following complications"]}
{"question": "A 27-year-old woman presents to her primary care physician for a general checkup. She has been doing well in school and has no complaints. The patient has a past medical history of asthma which is controlled with albuterol. She is currently sexually active but states that she uses birth control. She has many friends and states that her mood is typically positive. The patient's last pap smear was 1 year ago. Her father died of colon cancer at the age of 68, and her mother was diagnosed with breast cancer at the age of 65. Her temperature is 98.7°F (37.1°C), blood pressure is 147/108 mmHg, pulse is 80/min, respirations are 15/min, and oxygen saturation is 99% on room air. The patient's BMI is 19 kg/m^2. Physical exam demonstrates a normal S1 and S2, normal breath sounds, and an abdominal exam that is within normal limits. Which of the following is the best next step in management?", "answer": "Discontinue birth control and place an intrauterine device", "options": {"A": "Colonoscopy", "B": "Discontinue birth control and place an intrauterine device", "C": "Pap smear", "D": "Recommend weight loss"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old woman presents", "primary care physician", "general checkup", "well", "school", "complaints", "patient", "past medical", "controlled", "albuterol", "currently sexually active", "states", "uses birth control", "friends", "states", "mood", "positive", "patient's", "pap smear", "1 year", "father died of colon cancer", "age", "68", "mother", "diagnosed", "breast cancer", "age", "65", "temperature", "98", "blood pressure", "mmHg", "pulse", "80 min", "respirations", "min", "oxygen saturation", "99", "room air", "patient's BMI", "kg/m", "Physical exam demonstrates", "normal S1", "S2", "normal breath sounds", "abdominal exam", "normal limits", "following", "best next step", "management"]}
{"question": "A 25-year-old woman presents generalized abdominal pain and vomiting for the past hour. She has also had watery diarrhea for several days with no blood or pus in the stools. She is taking an over-the-counter anti-diarrheal medication, which she cannot remember the name of, and drinking oral rehydration solution, which has helped a little. Her past medical history shows she was hospitalized 10 years ago for an appendectomy and 4 years ago for a fractured ulna following a motor vehicle accident. Vital signs are pulse is 104/min, blood pressure is 120/80 mm Hg, respiratory rate of 14/min with shallow breathing, and temperature is 36.7°C (98.0°F). On physical examination, pupils are constricted. Extremities are pale and cold. The abdomen is soft but mildly, diffusely tender to palpation with a palpable bladder. No rebound or guarding. Fingerstick blood glucose is 124 mg/dL. Laboratory tests are pending. A urinary catheter is placed, and intravenous fluids are started. Abdominal imaging shows no abnormalities. Which of the following is the next best step in the management of this patient?", "answer": "Administer naloxone", "options": {"A": "Administer naloxone", "B": "Scopolamine patch", "C": "Start dextrose infusion", "D": "Perform a gastric lavage"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents generalized abdominal pain", "vomiting", "past hour", "watery diarrhea", "days", "blood", "pus in", "stools", "taking", "over-the-counter anti-diarrheal medication", "remember", "name", "drinking oral rehydration solution", "helped", "little", "past medical history shows", "hospitalized 10 years", "appendectomy", "4 years", "fractured ulna following", "motor vehicle accident", "Vital signs", "pulse", "min", "blood pressure", "80 mm Hg", "respiratory rate", "min", "shallow breathing", "temperature", "36", "98", "physical examination", "pupils", "constricted", "Extremities", "pale", "cold", "abdomen", "soft", "mildly", "tender", "palpation", "palpable bladder", "guarding", "Fingerstick blood glucose", "mg/dL", "Laboratory tests", "urinary catheter", "placed", "intravenous fluids", "started", "Abdominal imaging shows", "abnormalities", "following", "next best step", "management", "patient"]}
{"question": "A 26-year-old man with no significant past medical history presents to the ED following a motor vehicle accident. Vital signs on presentation are T 99.0 F, BP 100/60 mmHg, HR 125 bpm, RR 16/min, SpO2 98% on room air. He complains of extreme abdominal pain worse in the left upper quadrant which has worsened over the past 30 minutes. Exam demonstrates abdominal wall rigidity, involuntary guarding, and tenderness on light percussion. Bedside sonography shows evidence for hemoperitoneum. Despite administering more intravenous fluids, repeat vitals are T 98.9 F, BP 82/50 mm hg, HR 180 bpm, RR 20/min, SpO2 97% on room air. Which of the following is the best next step?", "answer": "Exploratory laparotomy", "options": {"A": "Normal saline bolus and re-evaluation of hemodynamics after infusion", "B": "CT abdomen and pelvis", "C": "Morphine", "D": "Exploratory laparotomy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "significant past medical history presents", "ED following", "motor vehicle accident", "Vital signs", "presentation", "T 99 0 F", "BP 100 60 mmHg", "RR", "min", "98", "room air", "extreme abdominal pain worse", "left upper quadrant", "worsened", "past 30 minutes", "Exam demonstrates abdominal rigidity", "involuntary guarding", "tenderness", "light percussion", "sonography shows evidence", "hemoperitoneum", "administering more intravenous fluids", "repeat", "T 98", "F", "BP", "50 mm hg", "RR 20 min", "97", "room air", "following", "best next step"]}
{"question": "A 74-year-old man undergoes an open cholecystectomy. Surgery is performed under general anesthesia for which the patient is intubated with an endotracheal tube. Directly following the procedure, his temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 110/80 mm Hg. He is extubated as soon as he showed signs of alertness. Five minutes later, he becomes unresponsive. He has type 2 diabetes mellitus, coronary artery disease, and hypertension. He underwent stenting of the right coronary artery 10 years ago. He smoked one pack of cigarettes daily for 40 years but quit 2 weeks ago for surgery. He drinks one to two beers daily. His current medications include metformin, enalapril, aspirin, atorvastatin, and a multivitamin. His temperature is 37°C (98.6°F), pulse is 102/min, respirations are 20/min, and blood pressure is 130/80 mm Hg. Pulse oximetry shows an oxygen saturation of 73%. He is put on a non-rebreather mask with an FiO2 of 100%. Three minutes later, he is still unresponsive. His arterial blood gas analysis shows:\npH 7.32\nPCO2 33 mm Hg\nPO2 73 mm Hg\nHCO3 22 mEq/L\nO2 saturation 73%\nWhich of the following is the best next step in the management of this patient?\"", "answer": "Reintubate", "options": {"A": "Perform tracheostomy", "B": "Continue using the non-rebreather mask", "C": "Reintubate", "D": "Start BiPAP"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["74 year old man", "open cholecystectomy", "Surgery", "performed", "general anesthesia", "patient", "intubated", "endotracheal tube", "Directly following", "procedure", "temperature", "98", "pulse", "80 min", "blood pressure", "80 mm Hg", "extubated", "showed signs", "alertness", "Five minutes later", "unresponsive", "type 2 diabetes mellitus", "coronary artery disease", "hypertension", "stenting", "right 10 years", "smoked one pack", "cigarettes daily", "40 years", "quit 2 weeks", "surgery", "drinks one", "two beers daily", "current medications include metformin", "enalapril", "aspirin", "atorvastatin", "multivitamin", "temperature", "98", "pulse", "min", "respirations", "20 min", "blood pressure", "80 mm Hg", "Pulse oximetry shows", "oxygen saturation", "put", "non-rebreather mask", "FiO2", "100", "Three minutes later", "unresponsive", "arterial blood gas analysis shows", "pH 7", "PCO2", "mm Hg PO2", "HCO3", "mEq/L O2 saturation", "following", "best next step", "management", "patient"]}
{"question": "An 11-month-old male infant is brought to his pediatrician by his mother. She is concerned about his leg and his inability to stand. He was born vaginally to a 33-year-old woman (gravida 3, para 2) from an uncomplicated pregnancy at 39 weeks. He has met all developmental milestones and is up to date on all vaccinations. His mother explains that he can normally stand without help and can walk briefly on his own. However, he hit his right leg against a chair 2 days ago. The area became edematous and bruised overtime and the infant became unable to stand or crawl and cries when he puts weight on it. The mother denies any child abuse from her family or child care. The patient’s vital signs are as follows: blood pressure 80/40 mm Hg, heart rate 137/min, respiratory rate 25/min, and temperature 36.7°C (97.0°F). His length and weight are both between the 15th and 25th percentile. On physical examination, blue-grayish discoloration of the sclerae are noted. Respiratory, cardiovascular, and abdominal examinations are within normal limits for his age. There is joint hypermobility and decreased tone in both upper and lower extremities. The patient’s right calf appears slightly deformed, edematous, and warm to the tough. The patient begins to cry loudly when the physician palpates his leg. The patient’s X-ray shows an incomplete fracture of the right tibial diaphysis. What is the most likely cause of the patient’s symptoms?", "answer": "Insufficient production of procollagen type 1", "options": {"A": "Insufficient production of procollagen type 1", "B": "Mutation in the gene encoding fibrillin-1", "C": "Defective collagen type 3", "D": "Dysfunctional structure of laminins"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["month old male infant", "brought", "pediatrician", "mother", "concerned", "leg", "stand", "born", "year old woman", "gravida 3", "para 2", "uncomplicated", "weeks", "met", "developmental milestones", "date", "vaccinations", "mother", "stand", "help", "walk", "hit", "right leg", "chair 2 days", "area", "edematous", "bruised overtime", "infant", "unable to stand", "crawl", "cries", "puts weight", "mother denies", "child abuse", "family", "child care", "patients vital signs", "follows", "blood pressure 80 40 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "length", "weight", "percentile", "physical examination", "blue grayish discoloration", "sclerae", "noted", "Respiratory", "cardiovascular", "abdominal examinations", "normal limits", "age", "joint hypermobility", "decreased tone", "upper", "lower extremities", "patients right calf appears slightly deformed", "edematous", "warm", "patient begins to cry", "physician palpates", "leg", "patients X-ray shows", "incomplete fracture", "right tibial diaphysis", "most likely cause", "patients symptoms"]}
{"question": "A 21-year-old man comes to the emergency room with swelling and severe pain in his left lower leg that started 2 hours ago. He has no history of serious illness or trauma. His father has a history of pulmonary embolism. He has smoked one pack of cigarettes daily since he started college 3 years ago. He appears very distressed. He is 173 cm (5 ft 8 in) tall and weighs 92 kg (203 lb); BMI is 30.7 kg/m2. His temperature is 37°C (98.6°F), pulse is 94/min, respirations are 17/min, and blood pressure is 130/78 mm Hg. Physical examination shows a tender and mildly swollen left lower leg; dorsiflexion of the left foot causes severe pain in the calf. Laboratory studies show a platelet count of 184,000/mm3, a prothrombin time of 11 seconds, an activated partial thromboplastin time of 26 seconds, and positive fibrin split products. Ultrasonography of the left leg shows incompressibility of the popliteal vein with a hyperechoic mass and absent blood flow. The patient is administered a 5000 IU intravenous bolus of unfractionated heparin followed by a constant infusion. Six hours later, the activated partial thromboplastin time is 30 seconds. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Antithrombin III deficiency", "options": {"A": "Antithrombin III deficiency", "B": "Factor V Leiden", "C": "Protein C deficiency", "D": "Antiphospholipid syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["21-year-old man", "emergency room", "swelling", "severe pain in", "left lower leg", "started 2 hours", "history", "serious illness", "trauma", "father", "history of pulmonary embolism", "smoked one pack", "cigarettes daily", "started college", "years", "appears very distressed", "5 ft 8", "tall", "kg", "BMI", "30", "kg/m2", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Physical examination shows", "tender", "mildly swollen left", "dorsiflexion of", "left foot causes severe pain in", "calf", "Laboratory studies show", "platelet count", "mm3", "prothrombin time", "seconds", "activated partial thromboplastin time", "seconds", "positive fibrin split products", "Ultrasonography", "left leg shows", "popliteal vein", "hyperechoic mass", "absent blood flow", "patient", "administered", "5000 IU intravenous bolus", "unfractionated heparin followed by", "constant infusion", "Six hours later", "activated partial thromboplastin time", "30 seconds", "following", "most likely cause", "patient's symptoms"]}
{"question": "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?", "answer": "Cardiac pacing", "options": {"A": "Dobutamine", "B": "Norepinephrine", "C": "Cardiac pacing", "D": "Epinephrine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["80 year old man", "brought", "emergency department", "fatigue", "lightheadedness", "not", "chest pain", "palpitations", "difficulty breathing", "history of hyperlipidemia", "type 2 diabetes mellitus", "hypertension", "osteoarthritis", "asthma", "Current medications include simvastatin", "metformin", "lisinopril", "albuterol", "ibuprofen", "pulse", "48 min", "blood pressure", "50 mm Hg", "slowly", "questions", "oriented to person", "place", "time", "Examination shows dry mucous membranes", "lungs", "clear", "auscultation", "bowel sounds", "positive", "pulsatile masses", "bruits", "Pedal pulses", "nonpalpable", "distal extremities", "cold", "capillary refill time", "4 seconds", "ECG shows left axis deviation", "Q wave", "lead III", "constant PR interval", "0.15 seconds", "third P wave", "QRS interval", "seconds", "following", "most appropriate next step", "management"]}
{"question": "In a small town with a population of 10,000 people, the prevalence of alcohol use is estimated to be 30%. A study is done with a null hypothesis that there is no association between alcohol use and gastro-oesophageal reflux disease (GERD). The data obtained shows, of the 200 alcoholics who were followed-up, 30 developed GERD; and out of the 400 non-alcoholics, 30 developed GERD. What fraction of GERD can be prevented in the general population if alcohol is no longer consumed in this town?", "answer": "45/195", "options": {"A": "45/195", "B": "30/400", "C": "(30/200) / (30/400)", "D": "30/200"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["small town", "population", "10", "people", "prevalence of alcohol use", "estimated to", "30", "study", "done", "null hypothesis", "association", "alcohol use", "gastro-oesophageal reflux disease", "GERD", "data obtained shows", "200 alcoholics", "followed", "30", "GERD", "out", "400 non alcoholics", "30", "GERD", "fraction of GERD", "prevented", "general population", "alcohol", "longer", "town"]}
{"question": "A 41-year-old man presents to the clinic with the complaints of abdominal discomfort and cramping for the past 4 months. He also mentions that he has grossly bloody stool and most of the time an urge to defecate. He has a history of bulimia with laxative abuse several years ago. He admits having lost about 5 lb in the past month. His temperature is 37° C (98.6° F), respiratory rate is 15/min, pulse is 77/min, and blood pressure is 105/86 mm Hg. On physical examination, a mild conjunctival pallor is evident, and the rectum is erythematous, indurated, and tender. Colonoscopy demonstrates continuous mucosal lesions throughout the rectum to the hepatic flexure of the colon. What is the most likely diagnosis?", "answer": "Ulcerative colitis", "options": {"A": "Ulcerative colitis", "B": "Celiac disease", "C": "Irritable bowel syndrome", "D": "Crohn’s disease"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "clinic", "complaints", "abdominal discomfort", "cramping", "past", "months", "bloody stool", "most of the time", "history", "bulimia", "laxative abuse", "years", "admits", "lost", "past month", "temperature", "98", "F", "respiratory rate", "min", "pulse", "min", "blood pressure", "mm Hg", "physical examination", "mild conjunctival pallor", "evident", "rectum", "erythematous", "indurated", "tender", "Colonoscopy demonstrates continuous mucosal lesions", "rectum", "the hepatic flexure of", "colon", "most likely diagnosis"]}
{"question": "A 45-year-old man presents to your office with a 2-year history of moderate-to-severe pelvic pain, irritative voiding urinary symptoms (frequency and dysuria), and occasional frank blood in his semen with painful ejaculation. He has been evaluated by several practitioners, who have all prescribed antimicrobial therapy, including ciprofloxacin, with no improvement and leading to emotional distress and sleep disturbances. The physical examination is unremarkable, except for a mildly tender prostate, without masses or nodules. There are no testicular masses, hernias, or hemorrhoids. Additionally to this health issue, you have also been following him for recurrent abdominal pain, periods of constipation and diarrhea, and fatigability, with all test results within the normal range thus far. A summary of recent tests is shown in the following table:\nUrine test\nSample White cells Culture\nMid-stream urine Negative Negative\nExpressed prostatic secretion Positive Negative\nWhat is the most likely diagnosis in this patient?", "answer": "Chronic, non-bacterial prostatitis", "options": {"A": "Benign prostatic hyperplasia", "B": "Chronic, non-bacterial prostatitis", "C": "Chronic prostatitis by resistant Escherichia coli", "D": "Interstitial cystitis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "office", "2 year history", "moderate-to-severe pelvic pain", "irritative voiding urinary symptoms", "frequency", "dysuria", "occasional", "blood in", "semen", "painful ejaculation", "evaluated", "practitioners", "prescribed antimicrobial therapy", "including ciprofloxacin", "improvement", "leading", "emotional distress", "sleep disturbances", "physical examination", "unremarkable", "mildly tender prostate", "masses", "nodules", "testicular masses", "hernias", "hemorrhoids", "health issue", "following", "recurrent abdominal pain", "periods", "constipation", "diarrhea", "fatigability", "test results", "normal range", "far", "summary", "recent tests", "shown", "following table", "Urine test Sample White cells Culture", "Expressed prostatic secretion Positive", "most likely diagnosis", "patient"]}
{"question": "An 18-year-old male presents to the emergency department trauma bay with a gunshot wound to the abdomen. The patient undergoes an exploratory laparotomy, during which, it is discovered that his splenic artery was damaged at its origin from the celiac trunk. The surgeon ligates the splenic artery at its origin. Which of the following arteries will now be hypoperfused as a result?", "answer": "Left gastroepiploic artery", "options": {"A": "Left gastric artery", "B": "Gastroduodenal artery", "C": "Left gastroepiploic artery", "D": "Common hepatic artery"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male presents", "emergency department trauma bay", "gunshot", "abdomen", "patient", "exploratory laparotomy", "discovered", "splenic artery", "damaged", "origin", "celiac trunk", "surgeon", "splenic artery", "origin", "following arteries", "now", "hypoperfused", "result"]}
{"question": "A 2-hour-old, 3.2 kg (7.0 lb) newborn boy born by cesarean delivery is being evaluated by the resident on-call. The child was born to a gravida 2, para 0 mother with known hepatitis B. The mother made it to all of her prenatal appointments and took the recommended dose of folic acid since conception. She gave up smoking when she discovered she was pregnant. The infant’s heart rate is 150/min, respiratory rate is 48/min, temperature is 37.5°C (99.5°F), and blood pressure is 80/52 mm Hg. APGAR testing exhibits a score of 7 and 8 at 1 and 5 minutes, respectively. The head is normocephalic. No neural tube defects are present on inspection or palpation of the spine. There is strong flexion in all 4 extremities. Cranial nerves 2–12 are intact. Sensory and deep tendon reflexes are without any abnormalities. Which of the following is the best course of action for the newborn child?\nHepatitis B serology\nHBsAg positive\nHBeAg positive\nIgM HBc negative\nTotal anti-HBc positive\nAnti-HBs negative\nAnti-HBc negative\nHBV DNA greater than 1 million IU/mL\nAlanine transferase normal", "answer": "Administer hepatitis B vaccine and HBIG", "options": {"A": "Administer hepatitis B vaccine", "B": "Administer hepatitis B immunoglobulin (HBIG)", "C": "Administer hepatitis B vaccine and HBIG", "D": "Check hepatitis B serology"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["2-hour old", "3.2 kg", "0", "newborn boy born", "cesarean delivery", "evaluated", "resident", "call", "child", "born", "gravida 2", "para 0 mother", "known hepatitis B", "mother made", "prenatal appointments", "took", "recommended dose", "folic acid", "conception", "gave", "smoking", "discovered", "pregnant", "infants heart rate", "min", "respiratory rate", "48 min", "temperature", "99", "blood pressure", "80", "mm Hg", "APGAR testing exhibits", "score", "8", "1", "5 minutes", "head", "neural tube defects", "present", "inspection", "palpation", "spine", "strong flexion", "extremities", "Cranial nerves", "intact", "Sensory", "deep tendon reflexes", "abnormalities", "following", "best course", "action", "newborn child", "Hepatitis B serology HBsAg positive HBeAg", "HBc negative", "anti", "HBs", "DNA greater than 1 million IU mL Alanine transferase normal"]}
{"question": "A 33-year-old man presents to the emergency department with a cough. He states that 2 weeks ago, he had a fever, chills, and a cough, which his primary doctor treated with acetaminophen, ibuprofen, and rest. Since then, the patient’s symptoms have resolved with the exception of a chronic cough and a small amount of clear sputum that is occasionally laced with blood. The patient denies chest pain, shortness of breath, fever, or chills. The patient is otherwise healthy and is currently taking metformin and albuterol. His temperature is 98.3°F (36.8°C), blood pressure is 129/75 mmHg, pulse is 84/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for bilateral clear breath sounds, absence of lymphadenopathy on HEENT exam, and a normal oropharynx. Which of the following is the best next step in management?", "answer": "Supportive care", "options": {"A": "Chest radiograph", "B": "D-dimer", "C": "Sputum culture", "D": "Supportive care"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "emergency department", "cough", "states", "2 weeks", "fever", "chills", "cough", "primary doctor treated with acetaminophen", "ibuprofen", "rest", "then", "patients symptoms", "resolved", "exception", "chronic cough", "small amount", "clear sputum", "occasionally laced", "blood", "patient denies chest pain", "shortness of breath", "fever", "chills", "patient", "healthy", "currently taking metformin", "albuterol", "temperature", "98", "36", "blood pressure", "75 mmHg", "pulse", "84 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "bilateral clear breath sounds", "absence", "lymphadenopathy", "HEENT exam", "normal oropharynx", "following", "best next step", "management"]}
{"question": "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?", "answer": "Tolterodine", "options": {"A": "Midodrine", "B": "Rivastigmine", "C": "Mirtazapine", "D": "Tolterodine"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["64 year old man", "multiple sclerosis", "physician", "of", "4 month history", "urinary incontinence", "to", "occurs", "often", "unable to make", "bathroom", "leaking urine", "incontinence", "coughing", "laughing", "Digital rectal examination shows", "abnormalities", "Ultrasonography shows", "normal post-void residual", "following", "most appropriate pharmacotherapy", "patient's incontinence"]}
{"question": "A 42-year-old woman with a history of depression and headaches presents to the emergency room with severe, pulsating pain around the crown of her head beginning 12 hours ago. She last took ibuprofen 2 hours ago but did not feel any improvement in the pain. She has been nauseous and unable to get out of bed and is currently laying in the dark with the lights off. Her depression has improved, and she has stopped taking her sertraline 2 months ago. Other than ibuprofen as needed, she is not currently taking any additional medications. Which of the following would be the best treatment for her acute symptoms?", "answer": "Sumatriptan", "options": {"A": "No treatment necessary", "B": "100% oxygen", "C": "Propranolol", "D": "Sumatriptan"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "history of depression", "headaches presents", "emergency room", "severe", "pulsating pain", "crown of", "head beginning 12 hours", "last took ibuprofen", "hours", "not feel", "improvement", "pain", "nauseous", "unable to get out", "bed", "currently laying", "dark", "lights", "depression", "improved", "stopped taking", "sertraline", "months", "ibuprofen as needed", "not currently taking", "additional medications", "following", "best treatment", "acute symptoms"]}
{"question": "A pulmonologist is analyzing the vital signs of patients with chronic obstructive pulmonary disease (COPD) who presented to an emergency room with respiratory distress and subsequently required intubation. The respiratory rates of 7 patients with COPD during their initial visit to the emergency room are shown:\nPatient 1 22 breaths per minute\nPatient 2 32 breaths per minute\nPatient 3 23 breaths per minute\nPatient 4 30 breaths per minute\nPatient 5 32 breaths per minute\nPatient 6 32 breaths per minute\nPatient 7 23 breaths per minute\nWhich of the following is the mode of these respiratory rates?\"", "answer": "32 breaths per minute", "options": {"A": "30 breaths per minute", "B": "32 breaths per minute", "C": "10 breaths per minute", "D": "27.7 breaths per minute"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["pulmonologist", "vital signs", "patients", "chronic obstructive pulmonary disease", "presented", "emergency room", "respiratory distress", "required intubation", "respiratory rates", "patients", "COPD", "initial visit", "emergency room", "shown", "Patient", "breaths per minute", "per minute Patient", "23 breaths", "30", "per minute Patient 5 32 breaths", "per minute Patient", "23 breaths", "following", "mode", "respiratory rates"]}
{"question": "A 17-year-old high school student was in shop class when he accidentally sawed off his pointer finger while making a bird house. He fainted when he realized his finger had been cut off. The teacher immediately transported the patient to the emergency department and he arrived within 20 minutes. He has a past medical history of asthma, and his only medication is an albuterol inhaler. The patient's current blood pressure is 122/78 mmHg. Analgesics are administered. The teacher states that he left the amputated finger in the classroom, but that the principal would be transporting it to the hospital. Which of the following is the correct method of transporting the amputated finger?", "answer": "Wrap finger in moist gauze, put in a plastic bag, and place on ice", "options": {"A": "Submerge the finger in ice water", "B": "Wrap the finger in moist gauze", "C": "Wrap finger in moist gauze, put in a plastic bag, and place on ice", "D": "Wrap the finger in moist gauze and submerge in ice water"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old high school student", "shop class", "sawed", "pointer finger", "making", "bird house", "fainted", "finger", "cut off", "teacher immediately transported", "patient", "emergency department", "arrived", "20 minutes", "past medical", "only medication", "albuterol inhaler", "patient's current blood pressure", "mmHg", "Analgesics", "administered", "teacher states", "left", "amputated finger", "classroom", "principal", "transporting", "hospital", "following", "correct method", "transporting", "amputated finger"]}
{"question": "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:\nProlactin 16 ng/mL\nThyroid-stimulating hormone 3.8 μU/mL\nFollicle-stimulating hormone 6 mIU/mL\nLuteinizing hormone 5.1 mIU/mL\nProgesterone 0.8 ng/mL (follicular N <3; luteal N >3–5)\nTestosterone 2.2 nmol/L (N <3.5)\nA urine pregnancy test is negative. Which of the following is the most likely cause of her symptoms?\"", "answer": "Anovulation", "options": {"A": "Uterine fibroids", "B": "Congenital defect of the Mullerian ducts", "C": "Purging behavior", "D": "Anovulation"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "physician", "not", "menstrual bleeding", "past 3 months", "Menses", "occurred", "irregular", "day intervals", "moderate", "heavy flow", "Menarche", "age", "years", "started", "sexual intercourse", "boyfriend", "3 months", "Six months", "manic episode", "treated with risperidone", "mother", "PCOS", "father", "diabetes mellitus", "very conscious", "weight", "appearance", "5 ft 6", "tall", "kg", "BMI", "27", "kg/m2", "temperature", "98", "pulse", "60 min", "blood pressure", "70 mm Hg", "abdomen", "soft", "nontender", "Pelvic examination shows", "normal vagina", "cervix", "Serum hormone studies show", "Prolactin", "Thyroid", "8 U", "Follicle-stimulating hormone", "mIU", "Luteinizing hormone", "Progesterone 0 8", "follicular", "3", "luteal", "35", "Testosterone", "nmol/L", "N", "3.5", "urine pregnancy test", "negative", "following", "most likely cause", "symptoms"]}
{"question": "A 21-year-old woman presents with sudden onset of high blood pressure. She is concerned about her health especially after her colleagues noticed that her face gets red at times while at work. She has even started to use blankets to cover her feet, even on the warmest days in the summer, even though her hands feel warm to the touch. She is a student who exercises and eats a well-balanced diet every day. There is no family history of hypertension or other metabolic syndromes. On examination, her blood pressure is 145/92 mm Hg, respirations are 19/min, pulse is 64/min, and temperature is 36.7°C (98.0°F). An echocardiogram is ordered for investigation. This patient is likely affected by a condition which is associated with which of the following options?", "answer": "Turner syndrome", "options": {"A": "Fibromuscular dysplasia", "B": "Marfan syndrome", "C": "Turner syndrome", "D": "Takayasu's arteritis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["21-year-old woman presents", "sudden onset", "high blood pressure", "concerned", "health", "face gets red", "times", "work", "started to use blankets to cover", "feet", "warmest days", "summer", "hands feel warm", "touch", "student", "exercises", "eats", "well balanced diet", "day", "family history of hypertension", "metabolic syndromes", "examination", "blood pressure", "mm Hg", "respirations", "min", "pulse", "64 min", "temperature", "36", "98", "echocardiogram", "ordered", "investigation", "patient", "likely affected", "condition", "associated with", "following options"]}
{"question": "A 52-year-old man presents to the physician with a 6-month history of shortness of breath and nonproductive cough. He was recently diagnosed with stage 3 embryonal carcinoma testicular cancer. Following an orchiectomy, he was placed on chemotherapy. Cardiopulmonary examination shows fine inspiratory crackles bilaterally. There is clubbing present in the fingers bilaterally. Pulmonary function tests (PFTs) show FVC is 78% of expected and FEV1/FVC ratio is 92%. A CT scan of the chest is shown. Which of the following drugs is responsible for the patient’s condition?", "answer": "Bleomycin", "options": {"A": "Bleomycin", "B": "Carboplatin", "C": "Cisplatin", "D": "Ifosfamide"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "physician", "month history of shortness", "breath", "nonproductive cough", "recently diagnosed", "stage 3 embryonal carcinoma testicular cancer", "Following", "orchiectomy", "placed", "chemotherapy", "Cardiopulmonary examination shows fine inspiratory crackles", "clubbing present", "fingers", "Pulmonary function tests", "show FVC", "expected", "FEV1/FVC ratio", "CT scan of", "chest", "shown", "following drugs", "responsible", "patients condition"]}
{"question": "A 72-year-old man develops reduced urine output and a serum creatinine concentration of 2.9 mg/dL three days after being hospitalized for acute diverticulitis. On admission, a complete blood count showed a hemoglobin concentration of 15.5 g/dL and a leukocyte count of 14,000/mm3. Urinalysis showed 2+ proteinuria, and serum studies showed a blood glucose of 145 mg/dL and a creatinine concentration of 1.2 mg/dL. A CT scan of the abdomen confirmed the diagnosis. Therapy with intravenous ketoprofen, piperacillin, and tazobactam was begun, and the patient was placed on bowel rest. He has a history of hypertension, chronic constipation, and type 2 diabetes mellitus. Prior to admission, his medications were insulin, metoprolol, and losartan. Today, his temperature is 37.7°C (99.9°F), pulse is 97/min, respirations are 12/min, and blood pressure is 135/87 mm Hg. The abdomen is soft on physical examination, and there is tenderness to palpation of the left lower quadrant. The remainder of the examination shows no abnormalities. Which of the following is the most likely cause of this patient's current renal findings?", "answer": "Contrast administration", "options": {"A": "Gastrointestinal blood loss", "B": "Adverse drug reaction", "C": "Dehydration", "D": "Contrast administration"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["72 year old man", "reduced urine output", "serum concentration", "2 9 mg dL three days", "hospitalized", "acute diverticulitis", "admission", "complete blood count showed", "hemoglobin concentration", "g/dL", "leukocyte count", "14", "mm3", "Urinalysis showed 2", "proteinuria", "serum studies showed", "blood glucose", "mg/dL", "creatinine concentration", "2 dL", "CT scan", "abdomen confirmed", "diagnosis", "Therapy", "intravenous ketoprofen", "piperacillin", "tazobactam", "begun", "patient", "placed", "bowel rest", "history of hypertension", "chronic constipation", "type 2 diabetes mellitus", "admission", "medications", "insulin", "metoprolol", "losartan", "Today", "temperature", "99 9F", "pulse", "97 min", "respirations", "min", "blood pressure", "87 mm Hg", "abdomen", "soft", "physical examination", "tenderness", "palpation", "left lower quadrant", "examination shows", "abnormalities", "following", "most likely cause", "patient's current renal findings"]}
{"question": "An immunology expert is delivering a talk on innate immunity. While talking about inflammasomes, he describes the process via an example: products of cellular stress are detected by NLRP3, which includes NOD-, LRR-, and pyrin domain-containing 3; the latter interacts with apoptosis-associated speck-like protein containing CARD (ASC) via the pyrin domain, which leads to the formation of a protein speck that consists of multimers of ASC dimers. Which of the following enzymes will be activated as the next step in the process?", "answer": "Caspase 1", "options": {"A": "Adenosine deaminase", "B": "Caspase 1", "C": "Protein phosphatase", "D": "Tyrosine kinase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["immunology", "delivering", "talk", "innate immunity", "talking", "inflammasomes", "process", "example", "products", "cellular stress", "detected", "NLRP3", "includes NOD", "LRR", "pyrin domain containing 3", "with apoptosis associated", "protein containing CARD", "ASC", "pyrin domain", "leads", "formation", "protein", "consists", "multimers", "ASC dimers", "following enzymes", "activated", "next step", "process"]}
{"question": "The ribosome is an essential organelle that plays an important role in the synthesis of new proteins. The location of the ribosome within the cell can vary and provides a clue to the function of the particular cell. What ribosome location is essential for protein-secreting cells?", "answer": "Rough endoplasmic reticulum", "options": {"A": "Rough endoplasmic reticulum", "B": "Smooth endoplasmic reticulum", "C": "Cytosol", "D": "Nucleus"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["ribosome", "essential organelle", "plays", "important role", "synthesis", "new proteins", "location", "ribosome", "cell", "provides", "clue", "function", "cell", "ribosome location", "essential", "protein-secreting cells"]}
{"question": "A patient presents to the emergency department with severe pain in her head. She states that the pain started 1 hour ago after rugby practice. Typically, she takes a special medication for bad headaches, but this time she took 2 doses and noticed no improvement in her symptoms. The patient's current medications that she can recall include sumatriptan and naproxen. She has been admitted to the hospital several times recently for panic attacks and suicide attempts. Her temperature is 99.2°F (37.3°C), blood pressure is 129/65 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. The patient is given dihydroergotamine, IV fluids, and is started on 100% oxygen. Two hours later, the patient demonstrates slurring of her speech. On physical exam there is drooping of the left side of her mouth, and her left upper extremity demonstrates 2/5 strength. A head CT is ordered. Which of the following is the most likely cause of this patient's current presentation?", "answer": "Medication reaction", "options": {"A": "Hemorrhagic stroke", "B": "Ischemic stroke secondary to a thrombus", "C": "Medication reaction", "D": "Psychogenic symptoms"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["patient presents", "emergency department", "severe pain", "head", "states", "pain started 1 hour", "rugby practice", "takes", "special medication", "bad headaches", "time", "took 2 doses", "improvement", "symptoms", "patient's current medications", "recall include sumatriptan", "naproxen", "admitted", "hospital", "times recently", "panic attacks", "suicide attempts", "temperature", "99", "3C", "blood pressure", "65 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "patient", "given dihydroergotamine", "IV fluids", "started", "100", "oxygen", "Two hours later", "patient demonstrates slurring", "speech", "physical exam", "drooping", "left side", "mouth", "left upper extremity demonstrates 2/5 strength", "head CT", "ordered", "following", "most likely cause", "patient's current presentation"]}
{"question": "A 24-year-old woman comes to the physician for a routine gynecological examination and to refill her birth control pills. Her last pap smear at age 22 showed no intraepithelial lesions nor malignancy of the cervical cells. Menses occur at regular 28-day intervals and last 4 days. Her last menstrual period was 2 weeks ago. She is sexually active with one male partner. Her father died of colon cancer at the age of 75 years and her mother was diagnosed with breast cancer at the age of 40 years. She mentions that she is planning a backpacking trip through Europe in 2 months. Her routine immunizations are all up-to-date. Her temperature is 36.9°C (98.5°F) and her blood pressure is 94/58 mm Hg. Pelvic and speculum examination show no abnormalities. Which of the following is the best recommendation for the patient at this time?", "answer": "Neisseria gonorrhoeae and Chlamydia trachomatis screening", "options": {"A": "Neisseria gonorrhoeae and Chlamydia trachomatis screening", "B": "Beta-hCG urine test", "C": "Repeat Pap smear", "D": "No further testing is necessary"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "routine gynecological examination", "to refill", "birth control pills", "last pap smear", "age", "showed", "intraepithelial lesions", "malignancy", "cervical", "Menses occur", "regular", "day intervals", "last 4 days", "last menstrual period", "2 weeks", "sexually active", "one male partner", "father died of colon cancer", "age", "75", "mother", "diagnosed", "breast cancer", "age", "40", "planning", "trip", "Europe", "2 months", "routine immunizations", "date", "temperature", "36", "98", "blood pressure", "58 mm Hg", "Pelvic", "speculum examination show", "abnormalities", "following", "best recommendation", "patient", "time"]}
{"question": "A 27-year-old man presents to the emergency department after a motor vehicle accident. The patient has a past medical history of asthma and cocaine use. His current medications include albuterol and ibuprofen. His temperature is 99.5°F (37.5°C), blood pressure is 70/35 mmHg, pulse is 150/min, respirations are 19/min, and oxygen saturation is 98% on room air. On initial trauma evaluation, his airway is intact and he is breathing spontaneously. The patient's dorsalis pedis and radial pulses are palpable bilaterally. His Glasgow Coma Scale is 9. Head to toe examination reveals instability of the pelvis when downwards force is applied. The patient is started on IV fluids and norepinephrine, and a pelvic binder is placed. The patient's vitals are measured again and his temperature is 99.5°F (37.5°C), blood pressure is 100/55 mmHg, pulse is 150/min, respirations are 17/min, and oxygen saturation is 98% on room air. A blood transfusion is started, and the patient is given hydromorphone. The patient suddenly becomes short of breath with notable bilateral wheezing with poor air movement. His blood pressure is 60/35 mmHg and pulse is 160/min. The patient is treated appropriately, intubated, stabilized, and transferred to the surgical intensive care unit. Which of the following is most likely to be found in this patient's history?", "answer": "Hemolytic anemia and ataxia", "options": {"A": "Hemolytic anemia and ataxia", "B": "Gum disease and poor wound healing", "C": "Irregularly irregular heart rhythm", "D": "Anti-A, B, or O antibodies in the serum"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["27 year old man presents", "emergency department", "motor vehicle accident", "patient", "past medical", "cocaine use", "current medications include albuterol", "ibuprofen", "temperature", "99", "blood pressure", "70 35 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "initial trauma", "airway", "intact", "breathing", "patient's", "radial pulses", "palpable", "Glasgow Coma Scale", "Head", "toe examination reveals instability", "pelvis", "downwards force", "applied", "patient", "started", "IV fluids", "norepinephrine", "pelvic binder", "placed", "patient's", "measured", "temperature", "99", "blood pressure", "100 55 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "blood transfusion", "started", "patient", "given hydromorphone", "patient", "short of breath", "notable bilateral wheezing", "poor air movement", "blood pressure", "60 35 mmHg", "pulse", "min", "patient", "treated", "intubated", "stabilized", "transferred", "surgical intensive care unit", "following", "most likely to", "found", "patient's history"]}
{"question": "An academic obstetrician is conducting a retrospective cohort study that evaluates the risk of placenta accreta at all statewide medical centers. Per chart review he finds that a prior cesarian birth is associated with a statistically significant increased risk of placenta accreta. The relative risk associated with this finding is 1.23. The associated p-value is 0.03. Which of the following statements is the best interpretation of the reported association in the context of the study?", "answer": "The 99% confidence interval includes the null hypothesis.", "options": {"A": "The 99% confidence interval includes the null hypothesis.", "B": "The chance of bias in favor of the alternative hypothesis is 3%.", "C": "The p-value represents the likelihood of seeing an increased risk of placenta accreta in women with prior cesarian birth, assuming the alternative hypothesis is true.", "D": "The p-value represents the likelihood that the alternative hypothesis is false."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["academic obstetrician", "conducting", "retrospective cohort study", "evaluates", "risk", "placenta accreta", "medical centers", "chart review", "finds", "prior cesarian birth", "associated with", "statistically significant increased risk", "placenta accreta", "relative risk associated", "finding", "1 23", "associated p-value", "0.03", "following statements", "best interpretation", "reported association", "context", "study"]}
{"question": "A 23-year-old man presents to his primary care physician after bleeding from his gums while brushing his teeth for the past week. Although he has had gum bleeding in the past, it has never been this severe. He has no family history available as he was adopted. He does not have any significant past medical history. His physical exam is within normal limits. Screening lab work is ordered with the following values:\nPlatelet count 330,000/mm3\nBleeding time 6 mins\nProthrombin time 12 sec\nActivated partial thromboplastin time 42 sec\nFactor VIII activity decreased\nRistocetin cofactor assay decreased\nHe is subsequently referred to a hematologist for further work-up and treatment. Which of the following aspects of coagulation would most likely be affected?", "answer": "Gp Ib", "options": {"A": "Gp Ib", "B": "Factor XI", "C": "Vitamin K", "D": "Antithrombin III"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["23 year old man presents", "primary care physician", "bleeding", "gums", "brushing", "teeth", "past week", "gum bleeding", "past", "never", "severe", "family history available", "adopted", "not", "significant past medical history", "physical exam", "normal limits", "Screening lab work", "ordered", "following values", "Platelet count 330", "mm3 Bleeding time", "mins Prothrombin", "sec Activated partial thromboplastin time", "activity decreased Ristocetin cofactor assay decreased", "referred to", "hematologist", "further work-up", "treatment", "following aspects", "coagulation", "most likely", "affected"]}
{"question": "A 51-year-old Caucasian woman presents to the physician for a routine health maintenance examination. She had a Colles' fracture 2 years ago. The rest of her past medical history is unremarkable. She has a sedentary lifestyle. She has been smoking 1 pack of cigarettes daily for 30 years. She drinks alcohol moderately. Her mother had a fracture of the wrist when she was in her late 60s. The physical examination shows no abnormal findings. Dual-energy X-ray absorptiometry (DEXA scan) shows a T-score of -3.2 standard deviations (SDs) in the hip. The patient is educated regarding her risk of falls. Exercise regimen and smoking cessation assistance are provided. Appropriate diet is indicated, as well as supplements with calcium and vitamin D. Which of the following is the most appropriate next step in pharmacotherapy?", "answer": "Alendronate", "options": {"A": "Alendronate", "B": "Calcitonin", "C": "Estrogen", "D": "Tamoxifen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old Caucasian woman presents", "physician", "routine health maintenance examination", "Colles", "fracture", "years", "rest", "past medical history", "unremarkable", "sedentary lifestyle", "smoking 1 pack", "cigarettes daily", "30 years", "drinks alcohol moderately", "mother", "fracture of", "wrist", "late", "physical examination shows", "abnormal findings", "Dual-energy X-ray absorptiometry", "DEXA scan", "shows a score", "3 2 standard deviations", "hip", "patient", "educated", "risk of falls", "Exercise regimen", "smoking cessation assistance", "provided", "Appropriate diet", "indicated", "supplements", "calcium", "vitamin D", "following", "most appropriate next step", "pharmacotherapy"]}
{"question": "A 33-year-old woman, gravida 2, para 1, at 26 weeks' gestation presents to the emergency department because of frequent contractions. The contractions last 40 seconds, occur every 2 minutes, and are increasing in intensity. She has a history of recurrent painful ulcers on her vulva, but she currently does not have them. Her first child was delivered by lower segment transverse cesarean section because of a non-reassuring fetal heart rate. Her current medications include acyclovir, folic acid, and a multivitamin. Her temperature is 36.9°C (98.4°F), heart rate is 88/min, and blood pressure is 126/76 mm Hg. Contractions are felt on the abdomen. The cervix is dilated to 5 cm, 70% effaced, and the station of the head is -2. A fetal ultrasound shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Allow vaginal delivery", "options": {"A": "Allow vaginal delivery", "B": "Initiate misoprostol therapy", "C": "Initiate nifedipine therapy", "D": "Perform dilation and evacuation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "weeks", "gestation presents", "emergency department", "frequent contractions", "contractions last 40 seconds", "occur", "2 minutes", "increasing", "intensity", "history", "recurrent painful ulcers", "vulva", "currently", "not", "first child", "delivered", "lower segment transverse cesarean", "non reassuring fetal heart rate", "current medications include acyclovir", "folic acid", "multivitamin", "temperature", "36", "98 4F", "heart rate", "88 min", "blood pressure", "76 mm Hg", "Contractions", "felt", "abdomen", "cervix", "dilated", "70", "station", "head", "2", "fetal ultrasound shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 55-year-old man presents with complaints of exertional dyspnea and dry cough. He reports using extra pillows at night to sleep and two nighttime awakenings to catch his breath in the last month. The patient lives in a homeless shelter and has not seen a doctor in the last 20 years. He has been drinking 5-8 drinks of alcohol per day for the last 20 years. Family history is non-significant, and the patient does not take any medications. His temperature is 37.1°C (98.9°F), blood pressure is 135/115 mm Hg, pulse is 85/min, and respiratory rate is 24/min. Physical examination reveals 2+ bilateral pitting edema. Chest auscultation reveals bibasilar crackles. Which of the following is associated with this patient’s condition?", "answer": "Increased renal tubular sodium reabsorption", "options": {"A": "Decreased glomerular filtration rate (GFR)", "B": "Decreased extracellular fluid (ECF) volume", "C": "Increased renal blood flow", "D": "Increased renal tubular sodium reabsorption"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["55 year old man presents", "complaints", "exertional dyspnea", "dry cough", "reports using extra pillows", "night to sleep", "two nighttime awakenings to catch", "breath", "month", "patient lives", "homeless shelter", "not seen", "doctor", "20 years", "drinking 5-8 drinks", "alcohol", "day", "20 years", "Family history", "non significant", "patient", "not take", "medications", "temperature", "98 9F", "blood pressure", "mm Hg", "pulse", "85 min", "respiratory rate", "min", "Physical examination reveals 2", "bilateral pitting edema", "Chest auscultation reveals", "crackles", "following", "associated with", "patients condition"]}
{"question": "A 22-year-old man presents to the medical clinic after getting bit in the hand by a stray dog 2 days ago. The patient has no past medical history and takes no prescription medications. He does not drink alcohol or smoke cigarettes. The patient’s vitals are currently within normal limits. On examination, the physician notices 2 clean puncture wounds with localized cellulitis. Capillary refill is 2 seconds. Sensorimotor evaluation of the hand is without deficits. Which of the following is the most appropriate treatment choice for this patient?", "answer": "Amoxicillin-clavulanate", "options": {"A": "Amoxicillin", "B": "Amoxicillin-clavulanate", "C": "Clindamycin", "D": "Doxycycline"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "medical clinic", "getting bit", "hand", "dog", "days", "patient", "past medical history", "takes", "prescription medications", "not drink alcohol", "smoke cigarettes", "patients", "currently", "normal limits", "examination", "physician", "clean puncture", "localized cellulitis", "Capillary refill", "2 seconds", "evaluation", "hand", "deficits", "following", "most appropriate treatment choice", "patient"]}
{"question": "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?", "answer": "Kwashiorkor", "options": {"A": "Kwashiorkor", "B": "Marasmus", "C": "Beriberi", "D": "Rickets"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old refugee", "increasing pitting edema", "abdominal swelling", "past", "months", "brought", "physician", "family", "displaced", "times", "years", "Nutrition", "housing", "frequently inadequate", "physicians clinic", "boy appears", "drowsy", "difficult", "Physical examination shows pitting", "ankles", "feet", "eyes", "Abdominal examination", "positive", "ascites", "hepatomegaly", "Oral examination shows several missing teeth", "following best", "findings"]}
{"question": "A 2-year-old boy is brought to his pediatrician by his parents for a routine visit. Since his 18-month visit, the parents have become concerned that his speech does not seem to be developing appropriately. The parents report that the patient’s vocabulary is still limited to fewer than 10 words, and he is still only using single words to describe things. The parents say that his motor milestones do not seem to be affected, as the patient is very physically active and can run and kick a ball. At times the patient seems hyperactive and can be difficult to redirect. On exam, his temperature is 98.4°F (36.9°C), blood pressure is 110/70 mmHg, pulse is 80/min, and respirations are 14/min. The rest of the exam is unremarkable, except that the patient’s face appears to be abnormally long and narrow. The patient is further referred to a geneticist, as he is believed to have a trinucleotide repeat disorder. Which of the following is the most likely inheritance pattern of this disorder?", "answer": "X-linked dominant", "options": {"A": "Autosomal dominant", "B": "Autosomal recessive", "C": "Noninherited somatic mutation", "D": "X-linked dominant"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["2 year old boy", "brought", "pediatrician", "parents", "routine visit", "month visit", "parents", "concerned", "speech", "not", "to", "parents report", "patients vocabulary", "limited", "10 words", "only using single words to", "things", "parents", "motor milestones", "not", "to", "affected", "patient", "very physically active", "run", "ball", "times", "patient", "hyperactive", "difficult", "exam", "temperature", "98 4F", "36", "blood pressure", "70 mmHg", "pulse", "80 min", "respirations", "min", "rest", "exam", "unremarkable", "except", "patients face appears to", "long", "narrow", "patient", "further referred", "geneticist", "to", "trinucleotide repeat disorder", "following", "most likely inheritance pattern", "disorder"]}
{"question": "A 23-year-old man is brought to the emergency department by his mother because of a change in his personality. The mother reports that over the past 7 months her son has become increasingly withdrawn; he has not answered any phone calls or visited his family and friends. He had always been a quiet boy, who needed some time on his own, but he used to meet with friends at least once a week. The patient says that he cannot leave the house because aliens are watching him and “stealing his thoughts”. He does not drink alcohol. He used to smoke marijuana occasionally but quit 1 year ago. His vital signs are within normal limits. Physical examination shows no abnormalities. On mental status examination, it is impossible to follow the patient's sequence of thoughts. He is anxious and has a flat affect. Which of the following is the most likely diagnosis?", "answer": "Schizophrenia", "options": {"A": "Delusional disorder", "B": "Mood disorder with psychotic features", "C": "Schizoid personality disorder", "D": "Schizophrenia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["23 year old man", "brought", "emergency department", "mother", "change", "personality", "mother reports", "past", "months", "son", "withdrawn", "not answered", "phone calls", "visited", "family", "friends", "always", "quiet boy", "needed", "time", "used to meet", "friends", "week", "patient", "leave", "house", "aliens", "watching", "stealing", "thoughts", "not drink alcohol", "used to smoke marijuana occasionally", "quit", "year", "vital signs", "normal", "Physical examination shows", "abnormalities", "mental", "to follow", "patient's sequence", "thoughts", "anxious", "flat affect", "following", "most likely diagnosis"]}
{"question": "A 37-year-old woman presents to the clinic with pain and swelling of her legs. She states that she first noticed the swelling 6 weeks ago. Initially, the swelling was minimal, but now she is finding it difficult to walk and she can’t fit into any of her shoes. Her medical history is significant for systemic lupus erythematosus. She takes ibuprofen and hydroxychloroquine. Her temperature is 99°F (37.2°C), blood pressure is 153/86 mmHg, and pulse is 88 beats/min. Pitting edema to bilateral knees is noted on physical examination. Urinalysis reveals proteinuria. The patient is started on an immunosuppressant. Two days later the patient returns to clinic complaining of blood in her urine. A urinalysis reveals moderate erythrocytes but is negative for leukocyte esterase, nitrites, or crystals. Diffuse oozing of the bladder mucosa with neovascularization is seen on cystoscopy. Which of the following could have prevented the patient’s condition?", "answer": "Mesna", "options": {"A": "Ifosfamide", "B": "Mesna", "C": "Methotrexate", "D": "Nitrofurantoin"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "clinic", "pain", "swelling of", "legs", "states", "first", "swelling", "weeks", "Initially", "swelling", "minimal", "now", "finding", "difficult to walk", "cant fit", "shoes", "medical history", "significant", "systemic lupus erythematosus", "takes ibuprofen", "hydroxychloroquine", "temperature", "blood pressure", "mmHg", "pulse", "88 beats/min", "Pitting", "bilateral knees", "noted", "physical examination", "Urinalysis reveals proteinuria", "patient", "started", "immunosuppressant", "Two days later", "patient returns", "clinic", "blood", "urine", "urinalysis reveals moderate erythrocytes", "negative", "leukocyte esterase", "nitrites", "crystals", "Diffuse", "bladder mucosa", "neovascularization", "seen", "cystoscopy", "following", "prevented", "patients condition"]}
{"question": "A 38-year-old woman presents to the office for a routine examination. She has no complaints and offers very little information voluntarily. She answers each question with soft, short sentences and avoids eye contact. She appears timid, anxious and admits that this is one of the very few times she has left the house in the last several years. Medical history is significant for essential hypertension. She takes hydrochlorothiazide and a daily vitamin. She has worked from home as a web graphic designer for 20 years. Questions about her social life reveal that she is very shy with few friends, and she often makes excuses to avoid parties and social gatherings. Despite this, she expresses a strong desire to be in a relationship. Today, her blood pressure is 125/85 mm Hg, heart rate is 95/min, respiratory rate is 18/min, and temperature is 37.0°C (98.6°F). On physical examination, her heart has a regular rhythm and her lungs are clear to auscultation bilaterally. Which of the following is most consistent with her behavior?", "answer": "Avoidant personality disorder", "options": {"A": "Schizoid personality disorder", "B": "Avoidant personality disorder", "C": "Antisocial personality disorder", "D": "Agoraphobia"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "office", "routine examination", "complaints", "very little information", "answers", "question", "soft", "short sentences", "eye contact", "appears timid", "anxious", "admits", "one", "very", "times", "left", "house", "years", "Medical history", "significant", "essential hypertension", "takes hydrochlorothiazide", "daily vitamin", "worked", "home", "web graphic designer", "20 years", "Questions", "social life reveal", "very shy", "friends", "often makes", "to", "parties", "social gatherings", "strong desire to", "relationship", "Today", "blood pressure", "85 mm Hg", "heart rate", "95 min", "respiratory rate", "min", "temperature", "98", "physical examination", "heart", "regular rhythm", "lungs", "clear", "auscultation", "following", "most consistent with", "behavior"]}
{"question": "A 3-year-old boy is brought to the emergency room by his mother after she found him somnolent at home next to multiple open pill bottles. The boy had seemingly opened several different pill bottles that were in a cabinet in his parent’s bathroom. The mother has brought the empty bottles to the emergency room, and they include aspirin, metoprolol, acetaminophen, levothyroxine, and lorazepam. The boy has no past medical history and takes no medications. His temperature is 98.6°F (37°C), blood pressure is 110/65 mmHg, pulse is 85/min, and respirations are 28/min. On exam, the boy is lethargic but responsive. He appears to be grasping at his ears and swaying from side-to-side when attempting to ambulate. He vomited once in the emergency room. Which of the following arterial blood gas readings is most likely to be found in this patient?", "answer": "pH 7.36, PCO2 22 mmHg, and HCO3- 16 mEq/L", "options": {"A": "pH 7.29, PCO2 47 mmHg, and HCO3- 22 mEq/L", "B": "pH 7.35, PCO2 29 mmHg, and HCO3- 15 mEq/L", "C": "pH 7.36, PCO2 22 mmHg, and HCO3- 16 mEq/L", "D": "pH 7.47, PCO2 41 mmHg, and HCO3- 29 mEq/L"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "emergency room", "mother", "found", "somnolent", "home next to multiple open pill bottles", "boy", "opened several different pill bottles", "cabinet", "parents bathroom", "mother", "brought", "empty bottles", "emergency room", "include aspirin", "metoprolol", "acetaminophen", "levothyroxine", "lorazepam", "boy", "past medical history", "takes", "medications", "temperature", "98", "blood pressure", "65 mmHg", "pulse", "85 min", "respirations", "min", "exam", "boy", "lethargic", "responsive", "appears to", "grasping", "ears", "side-to-side", "attempting to ambulate", "vomited", "emergency room", "following arterial blood gas readings", "most likely to", "found", "patient"]}
{"question": "A 38-year-old man presents with progressive tiredness and shortness of breath on exertion. Past medical history is significant for peptic ulcer disease diagnosed 2 years ago for which he is not compliant with his medications. He reports a 10-pack-year smoking history and occasionally alcohol use. His vital signs include: temperature 37.1°C (98.7°F), blood pressure 142/91 mm Hg, pulse 98/min. Physical examination is unremarkable. Laboratory findings are significant for the following:\nHemoglobin 9.7 g/dL\nHematocrit 29.1%\nRed cell count 3.7 million/mm3\nMean corpuscular volume (MCV) 71 μm3\nMean corpuscular hemoglobin (MCH) 21.3 pg/cell\nMean corpuscular hemoglobin concentration (MCHC) 28.4 Hb/cell\nReticulocyte count 0.2 %\nRed cell distribution width (RDW) 17.8 (ref: 11.5–14.5%)\nWhite blood cell count 8100/mm3\nPlatelet count 420,000/mm3\nIron studies show:\nTotal iron binding capacity (TIBC) 620 μg/dL\nTransferrin saturation 9%\nWhich of the following findings would most likely be found on a bone marrow biopsy in this patient?", "answer": "↓ hemosiderin stores", "options": {"A": "Hypocellularity with fatty infiltration", "B": "↓ hemosiderin stores", "C": "Ringed sideroblasts", "D": "Myeloblasts with immature precursors"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "progressive tiredness", "shortness of breath", "exertion", "Past medical history", "significant", "peptic ulcer disease diagnosed 2 years", "not compliant", "medications", "reports a 10 pack-year smoking history", "occasionally alcohol use", "vital signs include", "temperature", "98", "blood pressure", "mm Hg", "pulse 98 min", "Physical examination", "unremarkable", "Laboratory findings", "significant", "following", "Hemoglobin", "Hematocrit", "Red cell", "million mm3 Mean corpuscular volume", "71", "pg/cell", "0", "8", "ref", "White blood cell count", "Platelet", "Iron studies show", "Total iron binding capacity", "620 g/dL Transferrin saturation", "following findings", "most likely", "found", "bone marrow biopsy", "patient"]}
{"question": "A 27-year-old G3P1010 makes an appointment with her gynecologist for evaluation of profuse bleeding, which began two days ago. She is 13 weeks pregnant based on the date of her last menstrual period. She is dizzy and weak, and is unable to move around the house and perform her daily tasks. Initially, she had only light spotting, but later on in the day the bleeding increased. Thus far, she has used six sanitary pads. The blood pressure is 90/60 mm Hg, the temperature is 37.8°C (100°F), the pulse is 125/min, and the respiratory rate is 14/min. A saline infusion is started, and blood and urine specimens are sent for analysis. On pelvic examination, the vagina contains blood and the cervical os is open. She also complains of cervical motion and adnexal tenderness on examination. An ultrasound shows an intrauterine gestational sac low in the uterine cavity. No fetal movement or cardiac activity are observed. She is advised to rest for a couple of hours, after which the scan is repeated. Slight downward migration of the gestational sac is observed with no change in the fetal status. Which of the following is the next step in management?", "answer": "Dilation and curettage", "options": {"A": "Antibiotics", "B": "Magnesium sulfate", "C": "Methotrexate", "D": "Dilation and curettage"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old", "makes", "appointment", "gynecologist", "evaluation", "bleeding", "began two days", "weeks pregnant based", "date of", "last menstrual period", "dizzy", "weak", "unable to move", "house", "perform", "daily tasks", "Initially", "only light spotting", "later", "day", "bleeding increased", "far", "used six sanitary pads", "blood pressure", "90 60 mm Hg", "temperature", "pulse", "min", "respiratory rate", "min", "saline infusion", "started", "blood", "urine specimens", "sent", "analysis", "pelvic examination", "vagina contains blood", "cervical os", "open", "cervical motion", "adnexal tenderness", "examination", "ultrasound shows", "intrauterine gestational sac low", "uterine cavity", "fetal movement", "cardiac activity", "observed", "to rest", "couple", "hours", "scan", "repeated", "Slight downward migration", "gestational sac", "observed", "change", "fetal status", "following", "next step", "management"]}
{"question": "An otherwise healthy 25-year-old woman comes to the physician because of a 2-day history of pain and swelling of her right knee joint and left wrist. She went camping with her new boyfriend 3 weeks ago but does not recall any tick bites. Her temperature is 37.8°C (100.0°F). Examination of the right knee shows swelling, warmth, and tenderness on passive movement. There is a tender pustule on the sole of the left foot. Arthrocentesis of the right knee joint yields 8 mL of cloudy fluid with a leukocyte count of 45,000/mm3 (90% segmented neutrophils with intracellular organisms). Which of the following is the strongest risk factor for this patient's condition?", "answer": "Sexually transmitted infection", "options": {"A": "Autoantibody production", "B": "Intravenous drug use", "C": "Sexually transmitted infection", "D": "HLA-B 27 positivity"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old woman", "physician", "2-day history", "pain", "swelling of", "right knee joint", "left wrist", "camping", "new boyfriend", "weeks", "not recall", "tick bites", "temperature", "100", "Examination", "right knee shows swelling", "warmth", "tenderness", "passive movement", "tender pustule", "sole of", "left foot", "Arthrocentesis", "right knee joint", "mL", "cloudy fluid", "leukocyte count", "mm3", "90", "segmented neutrophils", "intracellular organisms", "following", "strongest risk factor", "patient's condition"]}
{"question": "A 54-year-old man comes to the clinic for management of his gastroesophageal reflux disease (GERD). He is currently on cimetidine for his condition and reports that his GERD initially improved. However, following his recent move to Michigan, he is experiencing more frequent episodes of chest pain (4-5 times a week). The pain is described as burning in quality and is concentrated around his epigastric region following food ingestion. It does not radiate anywhere and is alleviated when he takes antacids. A physical examination demonstrates a healthy male with unremarkable findings. He is subsequently prescribed a new medication for control of his symptoms. What is the most likely mechanism of action of this new medication?", "answer": "Irreversible inhibition of H+/K+-ATPase at parietal cells", "options": {"A": "Irreversible inactivation of cyclooxygenase enzyme", "B": "Irreversible inhibition of H+/K+-ATPase at parietal cells", "C": "Reversible inhibition of H+/K+-ATPase at parietal cells", "D": "Reversible inhibition of histamine H2 receptors"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["54 year old man", "clinic", "management", "gastroesophageal reflux disease", "currently", "cimetidine", "condition", "reports", "GERD initially improved", "following", "recent move", "Michigan", "experiencing more frequent episodes of chest pain", "4", "times", "week", "pain", "described", "burning", "quality", "concentrated", "epigastric region following food ingestion", "not radiate", "takes antacids", "physical examination demonstrates", "healthy male", "unremarkable findings", "prescribed", "new medication", "control", "symptoms", "most likely mechanism of action", "new medication"]}
{"question": "A 7-year-old boy is brought to the physician by his mother for evaluation of progressively worsening swelling around the eyes. He has no history of major medical illness. He had a sore throat and cough 2 weeks ago that resolved spontaneously. Physical examination shows moderate periorbital edema and 2+ pitting edema of the lower extremities bilaterally. A kidney biopsy specimen shows effacement of the podocytes on electron microscopy. Which of the following is most likely to be found on urinalysis?", "answer": "Fatty casts and albumin", "options": {"A": "Hyaline casts and immunoglobulins", "B": "Fatty casts and albumin", "C": "White blood cell casts and eosinophils", "D": "Granular casts and tubular epithelial cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "mother", "evaluation", "worsening swelling", "eyes", "history of major medical illness", "sore throat", "cough", "weeks", "resolved", "Physical examination shows moderate periorbital edema", "2", "pitting edema of", "lower extremities", "kidney biopsy specimen shows effacement", "podocytes", "electron microscopy", "following", "most likely to", "found", "urinalysis"]}
{"question": "Background: There is a lack of consensus about whether the initial imaging method for patients with suspected nephrolithiasis should be computed tomography (CT) or ultrasonography.\nMethods: In this multicenter, pragmatic, comparative effectiveness trial, we randomly assigned patients 18 to 76 years of age who presented to the emergency department with suspected nephrolithiasis to undergo initial diagnostic ultrasonography performed by an emergency physician (point-of-care ultrasonography), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal non-contrast CT. Subsequent management, including additional imaging, was at the discretion of the physician. We compared the three groups with respect to the 30-day incidence of high-risk diagnoses with complications that could be related to missed or delayed diagnosis and the 6-month cumulative radiation exposure. Secondary outcomes were serious adverse events, related serious adverse events (deemed attributable to study participation), pain (assessed on an 11-point visual-analog scale, with higher scores indicating more severe pain), return emergency department visits, hospitalizations, and diagnostic accuracy.\nResults: A total of 2759 patients underwent randomization: 908 to point-of-care ultrasonography, 893 to radiology ultrasonography, and 958 to non-contrast CT abdomen The incidence of high-risk diagnoses with complications in the first 30 days was low (0.4%) and did not vary according to imaging method. The mean 6-month cumulative radiation exposure was significantly lower in the ultrasonography groups than in the CT group (p < 0.001). Serious adverse events occurred in 12.4% of the patients assigned to point-of-care ultrasonography, 10.8% of those assigned to radiology ultrasonography, and 11.2% of those assigned to CT (p = 0.50). Related adverse events were infrequent (incidence, 0.4%) and similar across groups. By 7 days, the average pain score was 2.0 in each group (p = 0.84). Return emergency department visits, hospitalizations, and diagnostic accuracy did not differ significantly among the groups.\nConclusions: Initial ultrasonography was associated with lower cumulative radiation exposure than initial CT, without significant differences in high-risk diagnoses with complications, serious adverse events, pain scores, return emergency department visits, or hospitalizations.\nIf the conclusion stated above was, in fact, due to the earlier detection of nephrolithiasis in patients undergoing point of care ultrasound, what type of bias would this exemplify?", "answer": "Measurement bias", "options": {"A": "Measurement bias", "B": "Recall bias", "C": "Lead-time bias", "D": "Selection bias"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Background", "lack", "consensus", "initial imaging method", "patients", "suspected nephrolithiasis", "computed tomography", "ultrasonography", "Methods", "multicenter", "pragmatic", "effectiveness trial", "assigned patients", "76 years", "age", "presented", "emergency department", "suspected nephrolithiasis to", "initial diagnostic ultrasonography performed by", "emergency physician", "point-of-care ultrasonography", "ultrasonography performed by", "radiologist", "radiology ultrasonography", "abdominal non contrast CT", "Subsequent management", "including additional imaging", "physician", "compared", "three groups", "day incidence of high-risk diagnoses", "complications", "related", "missed", "delayed diagnosis", "month cumulative radiation", "Secondary outcomes", "serious adverse events", "related serious adverse events", "attributable to study participation", "pain", "assessed", "point visual-analog scale", "higher scores", "more severe pain", "return emergency department visits", "hospitalizations", "diagnostic accuracy", "Results", "total", "patients", "randomization", "point-of-care ultrasonography", "radiology ultrasonography", "non contrast", "incidence of high-risk diagnoses", "complications", "first 30 days", "low", "0.4", "not", "according", "imaging method", "mean", "month cumulative radiation", "lower", "ultrasonography groups", "CT group", "p", "0.001", "Serious adverse events occurred", "12.4", "patients assigned to point-of-care ultrasonography", "10.8", "assigned", "radiology ultrasonography", "assigned", "CT", "p", "0 50", "Related adverse events", "infrequent", "incidence", "0.4", "similar", "groups", "7 days", "average pain score", "2", "group", "p", "0 84", "Return emergency department visits", "hospitalizations", "diagnostic accuracy", "not", "groups", "Conclusions", "Initial ultrasonography", "associated with lower cumulative radiation", "initial CT", "significant differences", "high-risk diagnoses", "complications", "serious adverse events", "pain scores", "return emergency department visits", "hospitalizations", "conclusion stated", "due to", "earlier detection", "nephrolithiasis", "patients", "point of care ultrasound", "type", "bias"]}
{"question": "A 45-year-old woman comes to the emergency department because of intermittent chest pain and palpitations. She also complains of dyspnea on exertion and has had a 4.5-kg (10-lb) weight loss in the past 2 months despite normal appetite. She has no history of serious medical illness. Cardiac examination shows an irregularly irregular rhythm and a grade 3/6, low pitched, rumbling, mid-diastolic murmur heard best over the apex. Diffuse wheezing and bilateral rales are present in the lung bases. A transthoracic echocardiogram shows a left-ventricular ejection fraction of 40% and a mass in the left atrium. A biopsy of the mass is likely to show which of the following?", "answer": "Nests of atypical melanocytes", "options": {"A": "Nonencapsulated groups of well-differentiated skeletal muscle cells", "B": "Mixture of cells from different germinal layers", "C": "Encapsulated cluster of mature fat cells", "D": "Nests of atypical melanocytes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "emergency department", "intermittent chest", "palpitations", "dyspnea", "exertion", "4.5 kg", "10", "weight loss", "past", "months", "normal appetite", "history of serious medical illness", "Cardiac examination shows", "irregular rhythm", "grade", "6", "low pitched", "rumbling", "mid-diastolic murmur heard best", "apex", "Diffuse wheezing", "bilateral rales", "present", "lung bases", "transthoracic echocardiogram shows", "left-ventricular ejection fraction of 40", "mass", "left atrium", "biopsy", "mass", "likely to show", "following"]}
{"question": "A 58-year-old woman comes to the physician because of intermittent painful retrosternal dullness for 4 weeks. The pain is recurrent and occurs when she exerts herself or when she is outside during cold weather. She also experiences shortness of breath and palpitations during these episodes. The symptoms resolve spontaneously when she stops or sits down for a while. Over the past few days, the episodes have increased in frequency. She has hypertension, type 2 diabetes mellitus, and osteoarthritis. Her left leg was amputated below the knee after a motorcycle accident 25 years ago. She is currently waiting for a new prosthesis and walks with crutches. Current medications include captopril, glyburide, and ibuprofen. She does not smoke or drink alcohol. Her pulse is 88/min, respirations are 20/min, and blood pressure is 144/90 mm Hg. Cardiac examination shows no abnormalities. An x-ray of the chest shows no abnormalities. An ECG shows a normal sinus rhythm without any signs of ischemia. Serum cardiac markers are within the reference range. Which of the following is the most appropriate next step in diagnosis?", "answer": "Myocardial perfusion scan under pharmacological stress", "options": {"A": "Myocardial perfusion scan under pharmacological stress", "B": "Upper endoscopy", "C": "Coronary angiography", "D": "Echocardiography at rest"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old woman", "physician", "of intermittent dullness", "weeks", "pain", "recurrent", "occurs", "exerts", "outside", "cold weather", "experiences shortness of breath", "palpitations", "episodes", "symptoms resolve", "stops", "sits", "past", "days", "episodes", "increased", "frequency", "hypertension", "type 2 diabetes mellitus", "osteoarthritis", "left leg", "amputated", "knee", "motorcycle accident", "years", "currently waiting", "new prosthesis", "walks", "crutches", "Current medications include captopril", "glyburide", "ibuprofen", "not smoke", "drink alcohol", "pulse", "88 min", "respirations", "20 min", "blood pressure", "90 mm Hg", "Cardiac examination shows", "abnormalities", "x-ray of", "chest shows", "abnormalities", "ECG shows", "normal sinus rhythm", "signs", "ischemia", "Serum cardiac", "reference range", "following", "most appropriate next step", "diagnosis"]}
{"question": "A 24-year-old primigravida presents to her physician at 20 weeks gestation. She was diagnosed with asymptomatic bacteriuria at her last appointment 2 weeks ago, and was treated with amoxicillin. She has no concurrent diseases and no complaints. Her vital signs are as follows: blood pressure 110/80 mm Hg, heart rate 82/min, respiratory rate 11/min, and temperature 36.6℃ (97.7℉). The physical examination reveals no abnormalities. On gynecologic examination, the cervix is soft and non-tender with no discharge from the external os. The uterus is enlarged to the umbilicus and the fetal heart rate is normal. Which of the following statements is the most accurate with respect to the presented case?", "answer": "Urine culture should be performed in this patient again.", "options": {"A": "This patient does not require further urinary tests unless she becomes symptomatic.", "B": "Urinalysis should be performed on each subsequent antenatal visit to screen for possible recurrence of bacteriuria.", "C": "Urine culture should be performed in this patient again.", "D": "Urinalysis should be performed to check for leukocytes, blood, and bacteria; if positive, perform a urine culture."}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old primigravida presents", "physician", "20 weeks gestation", "diagnosed", "asymptomatic bacteriuria", "last appointment", "weeks", "treated with amoxicillin", "concurrent diseases", "complaints", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "physical examination reveals", "abnormalities", "gynecologic examination", "cervix", "soft", "non-tender", "discharge", "external os", "uterus", "enlarged", "umbilicus", "fetal heart rate", "normal", "following statements", "most accurate", "respect", "presented case"]}
{"question": "A 36-year-old G3P2 woman with no significant past medical history delivers a 3.7 kg (8 lb, 3 oz) baby boy following an uncomplicated pregnancy. On physical examination in the delivery room, the pediatrician notes that the baby has upslanting palpebral fissures, epicanthal folds, a flat facial profile, small ears, a single palmar crease, and hypotonia. When discussing the diagnosis with the parents, which of the following is this baby at an increased risk for having?", "answer": "Omphalocele", "options": {"A": "Tetralogy of Fallot", "B": "Omphalocele", "C": "Congenital cataracts", "D": "Cleft lip"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["36 year old", "woman", "significant past medical history delivers", "3", "kg", "3 oz", "baby boy following", "uncomplicated pregnancy", "physical examination", "delivery room", "pediatrician notes", "baby", "upslanting palpebral fissures", "epicanthal folds", "flat facial profile", "small ears", "single palmar crease", "hypotonia", "discussing", "diagnosis", "parents", "following", "baby", "increased risk"]}
{"question": "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?", "answer": "Melanoma", "options": {"A": "Lung cancer", "B": "Melanoma", "C": "Multiple myeloma", "D": "Thyroid cancer"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "complaint", "headache", "past 10 days", "headache", "diffuse", "dull", "character", "moderate", "intensity", "worse", "morning", "not associated with fever", "sensitivity to light", "sound", "experiences occasional nausea", "vomiting", "not", "similar headaches", "past", "blood pressure", "90 mm Hg", "pulse", "60 min", "body mass index", "kg/m2", "neurological examination reveals normal extraocular movements", "Mild bilateral papilledema", "present", "magnetic resonance imaging", "brain reveals", "solitary lesion", "left temporal region", "predominant hemorrhage", "Refer", "image", "of", "MRI", "brain", "following types", "cancer", "highest", "to cause", "brain lesion"]}
{"question": "A previously healthy 27-year-old woman comes to the physician because of a 2-month history of depressed mood and fatigue. During this time, she has had a 5-kg (11-lb) weight gain. She reports trouble concentrating at her job as a preschool teacher and has missed work several times in recent weeks due to generalized fatigue. She has smoked 2 packs of cigarettes daily for 10 years and is actively trying to quit smoking. A drug is prescribed that will treat the patient's mood disturbance and support smoking cessation. This patient should be counseled about which of the following possible side effects of this drug?", "answer": "Tachycardia", "options": {"A": "Hypotension", "B": "Urinary retention", "C": "Tachycardia", "D": "QTc prolongation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy 27 year old woman", "physician", "2 month history", "depressed mood", "fatigue", "time", "5 kg", "weight gain", "reports", "concentrating", "job", "preschool teacher", "missed work several times", "recent weeks", "generalized fatigue", "smoked 2 packs", "cigarettes daily", "10 years", "to quit smoking", "drug", "prescribed", "treat", "patient's", "support smoking cessation", "patient", "counseled", "of", "following possible side effects", "drug"]}
{"question": "A 37-year-old woman presents to her primary care physician after returning from her honeymoon in Cancun. A few days ago, she began to notice an eruption of small red bumps that cover her torso, back, and buttocks. The patient first thought she had acne, but became worried when the rash continued to itch. The patient denies other symptoms. Vital signs are within normal limits. Physical exam is notable for red papules and pustules scattered across the trunk, abdomen, back, and buttocks, while sparing the limbs. Closer examination indicates inflammation of the hair follicles. Culture yields motile, gram-negative rods that are non-lactose fermenting and oxidase positive. What other finding is commonly observed in the culture of the most likely organism?", "answer": "Blue-green pigment", "options": {"A": "Pink colonies", "B": "Blue-green pigment", "C": "Yellow sulfur granules", "D": "Red pigment"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "returning", "few days", "began to", "eruption", "small red", "cover", "torso", "back", "buttocks", "patient first thought", "acne", "worried", "rash continued", "itch", "patient denies", "symptoms", "Vital signs", "normal limits", "Physical exam", "notable", "red papules", "pustules scattered", "trunk", "abdomen", "back", "buttocks", "limbs", "examination", "inflammation of", "hair follicles", "Culture", "motile", "gram-negative rods", "non lactose", "oxidase positive", "finding", "observed", "culture", "likely organism"]}
{"question": "A 30-year-old female presents to her primary care provider complaining of 4 days of fever, malaise, dyspnea, and productive cough and has recently developed pleuritic chest pain. Her past medical history is notable for asthma and takes albuterol as needed. She does not smoke but drinks alcohol socially. Her family history is notable for cystic fibrosis in her paternal uncle and interstitial lung disease in her paternal grandfather. Her temperature is 101°F (38.3°C), blood pressure is 115/75 mmHg, pulse is 110/min, and respirations are 21/min. Rales are noted in the right lower lung, and a chest radiograph demonstrates focal consolidation in the right lower lung lobe. After initiating the appropriate treatment, she agrees to take part in a study assessing the immune response to lung infections. A protein is identified in her serum that is thought to be elevated in response to her condition. An amino acid sequence at the carboxy terminus of the protein is isolated and a fluorescent marker is added to the sequence. This labeled sequence is subsequently added to a gel containing a protein isolated from the cell surface of the patient’s own neutrophils and macrophages and subsequently labeled with another fluorescent marker. The sequence binds strongly to this protein as evidenced by increased fluorescence in the gel. What process does this sequence typically undergo in immunocompetent individuals?", "answer": "Isotype switching", "options": {"A": "Random assortment", "B": "Random nucleotide addition", "C": "VDJ recombination", "D": "Isotype switching"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["30 year old female presents", "primary care provider", "4 days", "fever", "malaise", "dyspnea", "productive cough", "recently", "pleuritic chest pain", "past medical history", "notable", "asthma", "takes albuterol as needed", "not smoke", "drinks alcohol", "family history", "notable", "cystic fibrosis", "paternal uncle", "interstitial lung disease", "paternal grandfather", "temperature", "3C", "blood pressure", "75 mmHg", "pulse", "min", "respirations", "min", "Rales", "noted", "right lower lung", "chest radiograph demonstrates focal consolidation", "right lower lung lobe", "initiating", "appropriate treatment", "agrees to take part", "study assessing", "immune response", "lung infections", "A protein", "identified", "serum", "thought to", "elevated", "response", "condition", "amino acid sequence", "carboxy terminus of", "protein", "isolated", "fluorescent marker", "added", "sequence", "labeled sequence", "added", "gel containing a protein isolated", "cell surface of", "patients", "neutrophils", "macrophages", "labeled", "fluorescent marker", "sequence binds", "protein", "evidenced", "increased fluorescence", "gel", "process", "sequence", "immunocompetent individuals"]}
{"question": "A 27-year-old graduate student is bitten by a coral snake while he was hiking alone through the woods and dies 2 hours later from respiratory failure. His body was discovered 7 hours later by a group of campers who promptly called the police. On arrival, the police found his body to be cold and stiff. Which of the following processes is responsible for the rigidity observed?", "answer": "Inhibition of cross-bridge cycling", "options": {"A": "Activation of muscle contraction by neurotoxins", "B": "Effect of low temperature on muscle proteins", "C": "Inhibition of cross-bridge cycling", "D": "Depletion of intracellular calcium"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old graduate student", "bitten", "coral snake", "hiking alone", "woods", "hours later", "respiratory failure", "body", "discovered 7 hours later", "a group", "called", "police", "arrival", "police found", "body to", "cold", "stiff", "following processes", "responsible", "rigidity observed"]}
{"question": "A 28-year-old G1P0 woman at 12 weeks estimated gestational age presents with malaise, joint pain, fever, and chills for the past 3 days. Physical examination reveals a mild lace-like rash and arthritis. The patient mentions her friend who is a medical student told her that her symptoms are suggestive of a parvovirus B19 infection which may adversely affect her baby. Which of the following statements regarding the effect of parvovirus B19 infection in this pregnant patient is correct?", "answer": "It can lead to hydrops fetalis secondary to fetal anemia.", "options": {"A": "It can lead to hydrops fetalis secondary to fetal anemia.", "B": "It can cause aplastic crisis in the neonate.", "C": "Fetal loss occurs in more than 40% of primary infections.", "D": "The neonate may be born with a typical slapped-cheek rash."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old", "woman", "weeks estimated gestational age presents", "malaise", "joint pain", "fever", "chills", "past 3 days", "Physical examination reveals", "mild lace", "rash", "arthritis", "patient", "friend", "medical student", "symptoms", "suggestive of", "parvovirus B19 infection", "affect", "baby", "following statements", "effect", "parvovirus B19 infection", "pregnant patient", "correct"]}
{"question": "A 52-year-old man with hypertension and hyperlipidemia comes to the emergency department 30 minutes after the sudden onset of substernal chest pain while sitting in a chair at home. He reports drinking 2 glasses of whiskey earlier that day, after a stressful day at work. Current medications include hydrochlorothiazide and atorvastatin. He has smoked one pack of cigarettes daily for the past 20 years. His pulse is 102/min, and blood pressure is 135/88 mm Hg. Cardiopulmonary examination shows normal heart sounds. An ECG obtained on arrival at the emergency department shows ST-segment elevations in the anterior leads. 15 minutes later, the patient's chest pain has resolved and a repeat ECG shows no abnormalities. Which of the following is the most likely underlying mechanism of this patient’s chest pain?", "answer": "Coronary artery vasospasm", "options": {"A": "Coronary artery vasospasm", "B": "Coronary artery vasodilation", "C": "Atherosclerotic plaque rupture", "D": "Pericardial inflammation"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "hypertension", "hyperlipidemia", "emergency department 30 minutes", "sudden onset", "substernal chest pain", "sitting", "chair at home", "reports drinking 2 glasses", "whiskey earlier", "day", "stressful day at work", "Current medications include hydrochlorothiazide", "atorvastatin", "smoked one pack", "cigarettes daily", "past 20 years", "pulse", "min", "blood pressure", "88 mm Hg", "Cardiopulmonary examination shows normal heart sounds", "ECG obtained", "arrival", "emergency department shows ST-segment elevations", "anterior leads", "15 minutes later", "patient's chest pain", "resolved", "repeat ECG shows", "abnormalities", "following", "most likely underlying mechanism of", "patients chest pain"]}
{"question": "A 5-year-old boy is brought to the emergency department by his mother because of a sudden loss of consciousness. He has asthma and has been hospitalized multiple times. His mother has type 2 diabetes mellitus. He is somnolent and diaphoretic. Serum studies show a glucose concentration of 22 mg/dL and a potassium concentration of 2.4 mEq/L. A dextrose infusion is administered, after which his glucose concentration normalizes and his symptoms improve. He is admitted to the hospital for further observation. Overnight, he has another episode of decreased consciousness. Serum studies taken during the episode show a glucose concentration of 19 mg/dL, an insulin concentration of 108 mIU/L (N=2.6–24.9), and a C-peptide concentration of 0.3 ng/mL (N = 0.8–3.1). Which of the following is the most likely diagnosis?", "answer": "Factitious disorder imposed on another\n\"", "options": {"A": "Malingering", "B": "Primary adrenal insufficiency", "C": "Conversion disorder", "D": "Factitious disorder imposed on another\n\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["5 year old boy", "brought", "emergency department", "mother", "of", "sudden loss", "consciousness", "asthma", "hospitalized multiple times", "mother", "type 2 diabetes mellitus", "somnolent", "diaphoretic", "Serum studies show", "glucose concentration", "mg/dL", "potassium concentration", "mEq/L", "dextrose infusion", "administered", "glucose concentration normalizes", "symptoms", "admitted", "hospital", "further observation", "Overnight", "episode of decreased consciousness", "Serum studies taken", "episode show", "glucose concentration", "mg/dL", "insulin concentration", "mIU/L", "N", "C-peptide concentration", "0.3 ng/mL", "N", "0 83 1", "following", "most likely diagnosis"]}
{"question": "A 66-year-old woman presents with urinary incontinence, difficulty urinating, incomplete voiding, and dull pain in the suprapubic region. She reports that she has not urinated for the past 2 days and that the urine leakage occurs during both day and night and is not associated with physical exertion. The medical history is significant for arterial hypertension and poorly controlled type 2 diabetes mellitus for 8 years, and depression for 3 years. She is prescribed amlodipine, valsartan, atorvastatin, metformin, and amitriptyline. Her weight is 75 kg (165 lb) and her height is 166 cm (5 ft 40 in). Her vital signs are as follows: blood pressure, 120/80 mm Hg; heart rate, 91/min; respiratory rate, 13/min; and temperature, 36.4℃ (97.5℉). The physical examination reveals lower abdominal tenderness with a distended urinary bladder that is palpated in the suprapubic region. The neurological examination shows decreased Achilles reflexes bilaterally, and diminished fine touch and vibratory sensation. On gynecologic examination, the cervix was normally positioned, mobile, and without any visible lesions. Bulging of the posterior vaginal wall was noted. The adnexa were not palpable. An ultrasound examination showed an overdistended urinary bladder with no structural abnormalities. Which of the following is  the next step in managing this patient?", "answer": "Bladder catheterization", "options": {"A": "Installing a vaginal pessary", "B": "Bladder catheterization", "C": "Cystostomy", "D": "Prescribing prostaglandin E2"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old woman presents", "urinary incontinence", "difficulty urinating", "incomplete voiding", "dull pain", "suprapubic region", "reports", "not", "past 2 days", "urine leakage occurs", "day", "night", "not associated with physical exertion", "medical history", "significant", "arterial hypertension", "poorly controlled type 2 diabetes mellitus", "years", "depression", "years", "prescribed amlodipine", "valsartan", "atorvastatin", "metformin", "amitriptyline", "weight", "75 kg", "height", "5 ft 40", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "97", "physical examination reveals lower abdominal tenderness", "distended urinary bladder", "palpated", "suprapubic region", "neurological examination shows decreased Achilles reflexes", "diminished fine touch", "vibratory sensation", "gynecologic examination", "cervix", "positioned", "mobile", "visible lesions", "Bulging of", "posterior vaginal wall", "noted", "adnexa", "not palpable", "ultrasound examination showed", "urinary bladder", "structural abnormalities", "following", "next step", "managing", "patient"]}
{"question": "A 69-year-old man presents to his primary care physician with hip and back pain. The patient states that this weekend he had a barbecue. When he was lifting a heavy object he suddenly felt pain in his lower back. He describes the pain as in his buttocks but states that at times it travels down his leg. The patient states that it feels, \"electrical.\" The patient has a past medical history of obesity, diabetes, depression, anxiety, diverticulosis, constipation, and a surgical repair of his anterior cruciate ligament. His current medications include metformin, insulin, lisinopril, fluoxetine, and sodium docusate. Which of the following is most likely to help confirm the diagnosis?", "answer": "Straight leg raise", "options": {"A": "Flexion, abduction, and external rotation of the thigh", "B": "Straight leg raise", "C": "Internal rotation of the extended hip", "D": "Radiography"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["69 year old man presents", "primary care physician", "hip", "back pain", "patient states", "weekend", "lifting", "heavy object", "felt pain", "lower back", "pain", "buttocks", "states", "times", "travels", "leg", "patient states", "feels", "electrical", "patient", "past medical", "diabetes", "depression", "anxiety", "diverticulosis", "constipation", "surgical repair", "anterior cruciate ligament", "current medications include metformin", "insulin", "lisinopril", "fluoxetine", "sodium docusate", "following", "most likely to help confirm", "diagnosis"]}
{"question": "A 61-year-old woman presents to an outpatient clinic with fatigue and mild neck pain for a month. She adds that she is having difficulty swallowing. She denies trouble with her breathing but endorses 5–10 lb of unintentional weight loss over the past few months. On physical exam, the patient’s fingernails appear flat and mild conjunctival pallor is noted. An upper barium esophagram shows an upper esophageal web. A complete blood count reveals:\nHb% 10 gm/dL\nTotal count (WBC) 11,000 /mm3\nDifferential count:\nNeutrophile 70%\nLymphocytes 25%\nMonocytes 5%\nESR 10 mm/hr\nWhat is the most likely diagnosis?", "answer": "Plummer-Vinson syndrome", "options": {"A": "Plummer-Vinson syndrome", "B": "Esophageal squamous cell carcinoma", "C": "Zenker’s diverticulum", "D": "Achalasia"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["61 year old woman presents", "outpatient clinic", "fatigue", "mild neck", "month", "adds", "difficulty swallowing", "denies trouble", "breathing", "510", "of unintentional weight loss", "past", "months", "physical exam", "patients fingernails appear flat", "mild conjunctival pallor", "noted", "upper barium esophagram shows", "upper esophageal web", "complete blood count reveals", "Hb", "10 gm dL Total count", "WBC", "mm3 Differential count", "Neutrophile 70", "Lymphocytes 25", "Monocytes 5", "ESR 10 mm", "most likely diagnosis"]}
{"question": "A 65-year-old female patient comes to the physician’s office for her annual check-up. The patient’s only complaint is that she feels her vision has been getting more blurry over the past year. The patient has a past medical history of diabetes diagnosed 20 years ago and osteoarthritis. Her medications include metformin, glimepiride, and ibuprofen as needed for pain. Fundoscopic examination of this patient reveals narrowing of retinal arteries and microaneurysms. This patient’s symptoms are likely caused by tissue specific differences in expression of which of the following enzymes?", "answer": "Sorbitol dehydrogenase", "options": {"A": "Sorbitol dehydrogenase", "B": "Galactocerebrosidase", "C": "Arylsulfatase A", "D": "Sphingomyelinase"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["65 year old female patient", "physicians office", "annual check-up", "patients only complaint", "feels", "vision", "getting more blurry", "past year", "patient", "past medical diabetes diagnosed 20 years", "osteoarthritis", "medications include metformin", "glimepiride", "ibuprofen as needed", "pain", "Fundoscopic examination of", "patient reveals narrowing of retinal arteries", "microaneurysms", "patients symptoms", "likely caused", "tissue specific differences", "expression", "following enzymes"]}
{"question": "A 3-year-old boy is brought to the physician for the evaluation of recurrent skin lesions. The episodes of lesions started at the age of 2 months and multiple treatment options have been attempted without success. He has also had several episodes of respiratory tract infections, enlarged lymph nodes, and recurrent fevers since birth. The boy attends daycare. His older brother has asthma. The patient's immunizations are up-to-date. He is at the 5th percentile for length and 10th percentile for weight. He appears ill. His temperature is 38°C (100.4°F), pulse is 100/min, and blood pressure is 100/60 mm Hg. Examination shows several raised, erythematous lesions of different sizes over the face, neck, groins, and extremities; some secrete pus. Cervical and axillary lymph nodes are enlarged bilaterally. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?", "answer": "Chronic granulomatous disease", "options": {"A": "Chronic granulomatous disease", "B": "Atopic dermatitis", "C": "Wiskott-Aldrich syndrome", "D": "Chediak-Higashi syndrome"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 year old boy", "brought", "physician", "evaluation", "recurrent skin lesions", "episodes of lesions started", "age", "months", "multiple treatment options", "attempted", "success", "several episodes of respiratory tract infections", "enlarged lymph nodes", "recurrent fevers", "birth", "boy attends daycare", "older brother", "asthma", "patient's immunizations", "date", "5th percentile", "length", "percentile", "weight", "appears ill", "temperature", "100 4F", "pulse", "100 min", "blood pressure", "100 60 mm Hg", "Examination shows several raised", "erythematous lesions of different sizes", "face", "neck", "groins", "extremities", "secrete pus", "Cervical", "axillary lymph nodes", "enlarged", "examination shows", "abnormalities", "following", "most likely diagnosis"]}
{"question": "A 53-year-old man presents to clinic with a six month history of shoulder pain that is especially bothersome at night. Over the weekend he \"strained his shoulder\" during a pick-up basketball game and reports an acute exacerbation of his pain symptoms. On exam, he complains of pain to palpation just below the acromion. You suspect he has torn his supraspinatus. If correct, which of these functional maneuvers would you expect to be deficient on physical exam?", "answer": "Initiation of abduction", "options": {"A": "Initiation of adduction", "B": "External rotation", "C": "Initiation of abduction", "D": "Internal rotation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "clinic", "six month history", "shoulder pain", "night", "weekend", "strained", "shoulder", "pick", "basketball game", "reports", "acute exacerbation", "pain symptoms", "exam", "pain", "palpation", "acromion", "suspect", "torn", "supraspinatus", "correct", "functional", "to", "deficient", "physical exam"]}
{"question": "A 58-year-old woman comes to the physician because of a 3-month history of left knee pain as well as stiffness upon waking for about 10–15 minutes. The pain is worse after standing a lot at work and when she climbs stairs. There is no history of trauma. She has hypercholesterolemia and hypertension. Her mother died of metastatic breast cancer 15 years ago, at the age of 65 years. She does not smoke or drink alcohol. Current medications include atorvastatin, labetalol, and aspirin. Over the past 2 months, she has been taking over-the-counter ibuprofen as needed for the joint pain. She is 163 cm (5 ft 4 in) tall and weighs 84 kg (185 lb); BMI is 31.8 kg/m2. Her temperature is 37°C (98.6°F), pulse is 88/min, and blood pressure is 114/68 mm Hg. Examination of the left knee shows tenderness on palpation of the anteromedial joint line; there is crepitus and pain with full flexion and extension. Serum uric acid concentration is 8.0 mg/dL and erythrocyte sedimentation rate is 15 mm/h. Which of the following is the most likely finding on imaging of the left knee?", "answer": "Osteophytes with joint-space narrowing on x-ray", "options": {"A": "Osteophytes with joint-space narrowing on x-ray", "B": "Diffuse lytic-sclerotic bone lesions on x-ray", "C": "Joint effusion and pannus on ultrasound", "D": "Fluid-filled pouch on ultrasound"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old woman", "physician", "3 month history", "left", "stiffness", "waking", "about", "minutes", "pain", "worse", "standing", "lot", "work", "climbs stairs", "history", "trauma", "hypercholesterolemia", "hypertension", "mother died of metastatic breast cancer", "years", "age", "65", "not smoke", "drink alcohol", "Current medications include atorvastatin", "labetalol", "aspirin", "past", "months", "taking over-the-counter ibuprofen as needed", "joint pain", "5 ft 4", "tall", "84 kg", "BMI", "31", "kg/m2", "temperature", "98", "pulse", "88 min", "blood pressure", "68 mm Hg", "Examination", "left knee shows tenderness", "palpation of", "anteromedial joint line", "crepitus", "pain", "full flexion", "extension", "Serum uric acid concentration", "0 mg/dL", "erythrocyte sedimentation rate", "mm/h", "following", "most likely finding", "imaging", "left knee"]}
{"question": "A 6-month-old boy presents to a pediatrician for the evaluation of recurrent bacterial infections. He has a history of a variety of bacterial infections since birth. Physical examination reveals light-colored skin with silver-colored hair. The pediatrician suspects an immunodeficiency disorder and decides to order several tests. Study of the boy’s neutrophils reveals that they contain large cytoplasmic vacuoles. Genetic studies show a mutation in the LYST gene. Which of the following is the most likely diagnosis in this patient?", "answer": "Chediak-Higashi syndrome", "options": {"A": "Acquired immunodeficiency syndrome (AIDS)", "B": "Common variable immunodeficiency", "C": "Chediak-Higashi syndrome", "D": "Leukocyte adhesion deficiency–1"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["month old boy presents", "pediatrician", "evaluation", "recurrent bacterial infections", "history of", "variety", "bacterial infections", "birth", "Physical examination reveals light-colored skin", "silver", "hair", "pediatrician suspects", "immunodeficiency disorder", "to order several tests", "Study", "boys neutrophils reveals", "contain large cytoplasmic vacuoles", "Genetic studies show", "mutation", "LYST", "following", "most likely diagnosis", "patient"]}
{"question": "A 48-year-old man with type II diabetes mellitus complicated by peripheral neuropathy presents to the emergency department for a foot wound that he noticed. He denies any pain, fevers, or chills. His temperature is 101°F (38.3°C), blood pressure is 150/80 mmHg, pulse is 80/min, and respirations are 22/min. An ulcer with associated erythema and purulence is noted on his foot. Based on his radiography, he is diagnosed with osteomyelitis and admitted to the hospital for partial amputation of his right foot. He is given appropriate prophylaxis for tetanus and discharged 5 hospital days later on antibiotics. He returns to the emergency department one week later with difficulty breathing. His temperature is 98°F (37°C), blood pressure is 100/70 mmHg, pulse is 130/min, respirations are 27/min, and oxygen saturation is 92% on room air. His amputated foot stump is erythematous and edematous but not tender to palpation. An electrocardiogram reveals sinus tachycardia. He requests something to help calm his breathing down. What is the next best step in management?", "answer": "CT angiography of the chest and give oxygen", "options": {"A": "Complete blood count, type and screen, and order 1 unit of blood", "B": "CT angiography of the chest and give oxygen", "C": "Deep wound culture and start piperacillin-tazobactam", "D": "Erythrocyte sedimentation rate and give oxycodone"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["48 year old man", "type II diabetes mellitus complicated", "peripheral neuropathy presents", "emergency department", "foot wound", "denies", "pain", "fevers", "chills", "temperature", "3C", "blood pressure", "80 mmHg", "pulse", "80 min", "respirations", "min", "ulcer with associated erythema", "purulence", "noted", "foot", "Based", "radiography", "diagnosed", "osteomyelitis", "admitted", "hospital", "partial amputation of", "right foot", "given appropriate prophylaxis", "tetanus", "discharged 5 hospital days later", "antibiotics", "returns", "emergency department one week later", "difficulty breathing", "temperature", "blood pressure", "100 70 mmHg", "pulse", "min", "respirations", "27 min", "oxygen saturation", "room air", "amputated foot stump", "erythematous", "edematous", "not tender", "palpation", "electrocardiogram reveals sinus tachycardia", "requests", "to help calm", "breathing", "next best step", "management"]}
{"question": "A 56-year-old man comes to the physician because of a 1-day history of sudden severe pain in his right great toe. Four months ago, he had an episode of severe joint pain involving his left knee that lasted several days and resolved with over-the-counter analgesics. He has a history of hypertension treated with hydrochlorothiazide and nephrolithiasis. Examination shows erythema, swelling, warmth, and tenderness of the right metatarsophalangeal joint; range of movement is limited by pain. His serum uric acid is 12 mg/dL. Arthrocentesis yields cloudy fluid with a leukocyte count of 18,500/mm3 (80% segmented neutrophils). Polarized light microscopy of the synovial fluid is shown. Which of the following is the mechanism of action of the most appropriate long-term pharmacotherapy for this patient's condition?", "answer": "Inhibition of xanthine oxidase", "options": {"A": "Increased conversion of uric acid to allantoin", "B": "Inhibition of phospholipase A", "C": "Inhibition of xanthine oxidase", "D": "Increased renal excretion of urate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "1-day history", "sudden severe", "right great toe", "Four months", "episode of severe joint involving", "left knee", "lasted", "days", "resolved", "over-the-counter analgesics", "history of hypertension treated with hydrochlorothiazide", "nephrolithiasis", "Examination shows erythema", "swelling", "warmth", "tenderness", "right", "range", "movement", "limited", "pain", "serum uric acid", "mg/dL", "Arthrocentesis", "cloudy fluid", "leukocyte count", "18 500 mm3", "80", "segmented neutrophils", "Polarized light microscopy", "synovial fluid", "shown", "following", "mechanism of action", "appropriate long-term pharmacotherapy", "patient's condition"]}
{"question": "A 45-year-old man presents to the emergency department with severe dyspnea, wheezing, and palpitations. His symptoms began approx. 20 minutes after being stung by a bee on the left arm. Past medical history is significant for hypertension for which he takes labetalol. While being questioned, the patient becomes obtunded. His vital signs include: temperature 37.0°C (98.6°F); blood pressure 85/55 mm Hg; pulse 110/min; respiratory rate 31/min; and oxygen saturation 90% on room air. On physical examination, an area of severe edema and erythema is noted on the extensor surface of the left forearm, and there is severe angioedema of the face and neck. The patient is intubated, and aggressive fluid resuscitation and intramuscular epinephrine are administered. A repeat blood pressure is 90/55 mm Hg, despite these efforts. Which of the following is the next best step in the management of this patient?", "answer": "Administer glucagon", "options": {"A": "Administer dopamine", "B": "Administer glucagon", "C": "Administer dexamethasone", "D": "Administer norepinephrine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man presents", "emergency department", "severe dyspnea", "wheezing", "palpitations", "symptoms began", "20 minutes", "stung", "bee", "left arm", "Past medical history", "significant", "hypertension", "takes labetalol", "questioned", "patient", "obtunded", "vital signs include", "temperature", "98", "blood pressure 85 55 mm Hg", "pulse", "min", "respiratory rate 31 min", "oxygen 90", "room air", "physical examination", "area", "severe edema", "erythema", "noted", "extensor surface of", "left forearm", "severe angioedema", "face", "neck", "patient", "intubated", "aggressive fluid resuscitation", "intramuscular epinephrine", "administered", "repeat blood pressure", "90 55 mm Hg", "efforts", "following", "next best step", "management", "patient"]}
{"question": "A 74-year-old man has been treated for prostate cancer for the past 6 months. He is on an experimental drug (drug X) that is used to reduce the action of testosterone by blocking the androgen receptor. Since the initiation of therapy, the growth of the cancerous tissue has slowed. This medication is known to be excreted by the kidneys at the current dose that he is taking. The patient has no significant complaints, except for excessive sweating at times. On physical examination, a small area of tissue around his nipples is enlarged bilaterally. No other abnormal findings are present. Which of the following drugs most likely belongs to be the same class as drug X?", "answer": "Flutamide", "options": {"A": "Leuprolide", "B": "Finasteride", "C": "Flutamide", "D": "Anastrozole"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["74 year old man", "treated", "prostate cancer", "past 6 months", "experimental drug", "drug", "used to", "action", "testosterone", "blocking", "androgen receptor", "initiation", "therapy", "growth", "cancerous tissue", "slowed", "medication", "known to", "excreted", "kidneys", "current dose", "taking", "patient", "significant complaints", "except for excessive sweating", "times", "physical examination", "small area", "tissue", "nipples", "enlarged", "abnormal findings", "present", "following drugs", "likely", "to", "same class", "drug"]}
{"question": "A 74-year-old man was admitted to the hospital after falling down several stairs. He is a known alcoholic. He was started on IV fluids and received a head CT, which was negative. It was decided that he would be watched for one day before being discharged, after a negative work-up. Suddenly, he is unable to move his arms and legs in addition to experiencing difficulty chewing, swallowing, moving his face, and speaking. Which of the following electrolyte imbalances was most likely corrected too aggressively?", "answer": "Hyponatremia", "options": {"A": "Hyponatremia", "B": "Hypernatremia", "C": "Hypokalemia", "D": "Hypochloremia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["74 year old man", "admitted", "hospital", "falling down", "stairs", "known alcoholic", "started", "IV fluids", "received", "head CT", "negative", "one day", "discharged", "negative work-up", "unable to move", "arms", "legs in addition to experiencing difficulty chewing", "swallowing", "moving", "face", "speaking", "following electrolyte imbalances", "most likely corrected"]}
{"question": "A previously healthy 67-year-old man comes to the physician for routine health maintenance evaluation. He works at a community center and volunteers at a local homeless shelter. A tuberculin skin test shows an induration of 14 mm. An x-ray of the chest is normal. Treatment with an antimycobacterial drug is initiated. Two months later, he has numbness and burning over both feet and an unsteady gait. Physical examination shows decreased sensation to light touch extending from the soles of the feet to the mid-shin bilaterally. Which of the following is the most likely cause of this patient’s current symptoms?", "answer": "Accumulation of S-adenosylmethionine", "options": {"A": "Accumulation of S-adenosylmethionine", "B": "Intracellular accumulation of sorbitol", "C": "Segmental demyelination of peripheral axons", "D": "Impaired breakdown of glucose to ATP"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy 67 year old man", "physician", "routine health evaluation", "works", "community center", "volunteers", "local homeless shelter", "tuberculin skin test shows", "induration", "mm", "x-ray of", "chest", "normal", "Treatment", "antimycobacterial drug", "initiated", "Two months later", "numbness", "burning", "feet", "unsteady gait", "Physical examination shows decreased", "light extending", "soles of", "feet", "shin", "following", "most likely cause", "patients current symptoms"]}
{"question": "A 64-year-old male presents to his primary care physician with a complaint of bilateral knee pain that has been present for the past several years but has worsened recently. He reports pain with climbing stairs and with extended walks of greater than 100 yards. The pain worsens with activity throughout the day and is alleviated by periods of rest. He states that he has minimal morning stiffness, lasting approximately 5-10 minutes after waking up most days. Physical examination reveals tenderness to palpation of the bony structures on the medial aspect of the bilateral knees as well as crepitus and a decreased range of motion, limited at the extremes of flexion and extension. Both knee joints are cool to touch and exhibit bony enlargement upon palpation of the medial joint line. Which of the following studies would be indicated for further work-up of this patient's presenting condition?", "answer": "No further work-up needed", "options": {"A": "Complete blood count (CBC)", "B": "Erythrocyte sedimentation rate (ESR)", "C": "MRI of the knee", "D": "No further work-up needed"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["64 year old male presents", "primary care physician", "complaint", "bilateral knee pain", "present", "past", "years", "worsened recently", "reports pain", "climbing stairs", "extended walks", "greater", "100 yards", "pain worsens", "activity", "day", "periods", "rest", "states", "minimal morning stiffness", "lasting approximately 5 minutes", "waking", "days", "Physical examination reveals tenderness", "palpation", "bony", "medial aspect of", "bilateral knees", "crepitus", "decreased range of motion", "limited", "extremes", "flexion", "extension", "knee joints", "cool", "touch", "exhibit bony enlargement", "palpation", "medial joint line", "following studies", "indicated", "further work-up", "patient's presenting condition"]}
{"question": "A 4-year-old girl is brought to the physician because of pallor and rash for 2 days. She had a 4-day history of diarrhea and vomiting that subsided two days ago. One month ago, she had a 3-day episode of high fever, followed by a rash with bright red discoloration over her cheeks for two days before subsiding without treatment. Her vaccinations are up-to-date. She appears pale and irritable. Her vital signs are within normal limits. Examination shows petechiae on her trunk and extremities. Abdominal examination shows diffuse abdominal tenderness with hyperactive bowel sounds. The remainder of the exam shows no abnormalities. Laboratory studies show:\nHemoglobin 8 g/dL\nMean corpuscular volume 82 fL\nLeukocyte count 17,000/mm3\nPlatelet count 49,000/mm3\nProthrombin time 12 seconds\nPartial thromboplastin time 34 seconds\nSerum\nUrea nitrogen 42 mg/dL\nCreatinine 1.4 mg/dL\nBilirubin\nTotal 3 mg/dL\nIndirect 2.8 mg/dL\nLactate dehydrogenase 300 U/L\nUrine\nBlood 2+\nProtein 2+\nA peripheral blood smear shows schistocytes. Which of the following is the most likely underlying cause of these findings?\"", "answer": "Escherichia coli infection", "options": {"A": "Escherichia coli infection", "B": "Disseminated intravascular coagulation", "C": "Immune thrombocytopenic purpura", "D": "Thrombotic thrombocytopenic purpura"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["4 year old girl", "brought", "physician", "pallor", "rash", "2 days", "4-day history", "diarrhea", "vomiting", "two days", "One month", "3-day episode of high fever", "followed by", "rash", "bright red discoloration", "cheeks", "two days", "treatment", "vaccinations", "date", "appears pale", "irritable", "vital signs", "normal limits", "Examination shows petechiae", "trunk", "extremities", "Abdominal examination shows diffuse abdominal tenderness", "hyperactive bowel sounds", "exam shows", "abnormalities", "Laboratory studies show", "g", "Mean corpuscular volume", "Leukocyte", "12", "Partial thromboplastin time", "Serum", "mg", "4 mg", "2", "Lactate dehydrogenase", "L Urine", "Protein", "peripheral blood smear shows schistocytes", "following", "most likely underlying cause", "findings"]}
{"question": "A 76-year-old man presents to the physician because of dyspepsia and weight loss over the past 6 months. He has no history of any serious illnesses and takes no medications. A diagnostic workup including endoscopy and biopsy shows gastric adenocarcinoma. Before further workup and staging, the biopsy results are discussed with the patient. He refuses any type of life-prolonging treatment, including chemotherapy, radiation, or surgery, but he requests appropriate palliative care without any significant burden of healthcare costs. Regarding this patient’s eligibility for hospice care, what is the most appropriate next step?", "answer": "Determining patient’s life-expectancy without treatment", "options": {"A": "A trial of life-extending treatment", "B": "Determining patient’s life-expectancy without treatment", "C": "Establishing the presence of metastasis", "D": "No further steps are required because the patient already qualifies for hospice care"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["76 year old man presents", "physician", "dyspepsia", "weight loss", "past 6 months", "history", "serious illnesses", "takes", "medications", "diagnostic workup including endoscopy", "biopsy shows gastric adenocarcinoma", "further workup", "staging", "biopsy results", "discussed with", "patient", "refuses", "type", "life", "treatment", "including chemotherapy", "radiation", "surgery", "requests appropriate palliative care", "significant burden", "healthcare costs", "patients eligibility", "hospice care", "most appropriate next step"]}
{"question": "A 29-year-old female presents to the clinic for a regular check-up. She has no specific complaints. Vital signs include: blood pressure is 130/80 mm Hg, heart rate is 76/min, respiratory rate is 15/min, and temperature is 36.8°C (98.2°F). Her physical examination is within normal limits. The woman’s complete blood count shows an absolute increase in the cells shown in the first image. Which of the following is true regarding these cells?", "answer": "These cells transform to macrophages when they migrate to peripheral tissues.", "options": {"A": "These cells transform to macrophages when they migrate to peripheral tissues.", "B": "These cells express CD25 on their surfaces.", "C": "These cells normally constitute 25–40% of total leucocyte count.", "D": "These cells have lymphoid origin."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old female presents", "clinic", "regular check-up", "specific complaints", "Vital signs include", "blood pressure", "80 mm Hg", "heart rate", "76 min", "respiratory rate", "min", "temperature", "36", "98", "physical examination", "normal limits", "complete blood count shows", "absolute increase", "cells shown", "first image", "following", "true", "cells"]}
{"question": "A 23-year-old woman presents to the emergency department with abdominal pain. The patient states she has pain in the right side of her abdomen which started yesterday and has been worsening. She has experienced a few episodes of vomiting and diarrhea during this time. The patient has a past medical history of constipation which is treated with fiber supplements. Her temperature is 99.5°F (37.5°C), blood pressure is 110/68 mmHg, pulse is 110/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a young woman who appears to be in pain. Cardiopulmonary exam is within normal limits. Abdominal exam is notable for right lower quadrant pain that is reproducible when the left lower quadrant is palpated. The patient is given morphine. Which of the following is the next best step in management?", "answer": "ß-hCG", "options": {"A": "Abdominal radiograph", "B": "ß-hCG", "C": "CT scan", "D": "Stool occult blood"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["23 year old woman presents", "emergency department", "abdominal pain", "patient states", "pain", "right side", "abdomen", "started", "worsening", "experienced", "few episodes of vomiting", "diarrhea", "time", "patient", "past medical constipation", "treated with fiber supplements", "temperature", "99", "blood pressure", "68 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "physical exam", "note", "young woman", "appears to", "pain", "Cardiopulmonary exam", "normal limits", "Abdominal exam", "notable", "right lower quadrant pain", "reproducible", "left lower quadrant", "palpated", "patient", "given morphine", "following", "next best step", "management"]}
{"question": "A 24-year-old Asian woman is admitted to the hospital at 30 weeks gestation with nausea, vomiting, and right upper quadrant pain. She is gravida 2 para 0 with a history of the same complaints in her last pregnancy which ended with a stillbirth at the 31st week. Her older sister had preeclampsia in both of her pregnancies. Currently, the patient is responsive but lethargic. The vital signs are as follows: blood pressure 150/90 mm Hg, heart rate 85/min, respiratory rate 15/min, and temperature 36.4°C (97.5°F). The physical examination shows jaundice, right upper quadrant tenderness, and 2+ pitting edema of the lower extremities. The patient’s laboratory findings are as follows:\nErythrocyte count 2.7 million/mm3\nHemoglobin 10.1 g/dL\nHematocrit 0.56\nReticulocyte count 1.1%\nLeukocyte count 8,300/mm3\nThrombocyte count 190,000/mm3\nTotal bilirubin 5.3 mg/dL (91 µmol/L)\nConjugated bilirubin 4.2 mg/dL (72 µmol/L)\nAlanine Transaminase (ALT) 101 U/L\nAspartate Transaminase (AST) 99 U/L\nCreatinine 0.9 mg/dL (80 µmol/L)\nWhich of the following factors is a risk factor for this patient’s condition?", "answer": "History in the previous pregnancy", "options": {"A": "The patient’s age", "B": "Nulliparity", "C": "History in the previous pregnancy", "D": "History of preeclampsia in a sibling"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old Asian woman", "admitted", "hospital", "30 weeks gestation", "nausea", "vomiting", "right upper quadrant pain", "gravida 2 para 0", "history", "same complaints", "last pregnancy", "ended", "stillbirth", "week", "older sister", "preeclampsia", "pregnancies", "Currently", "patient", "responsive", "lethargic", "vital signs", "follows", "blood pressure", "90 mm Hg", "heart rate 85 min", "respiratory rate", "min", "temperature 36 4C", "97", "physical examination shows jaundice", "right upper quadrant tenderness", "2", "pitting edema of", "lower extremities", "patients laboratory findings", "follows", "Erythrocyte count", "million mm3 Hemoglobin", "g dL", "0", "Leukocyte count 8 300", "Thrombocyte", "Total bilirubin 5", "dL", "mol/L", "Conjugated bilirubin", "mg/dL", "72 mol/L", "Alanine", "U/L Aspartate Transaminase", "99", "Creatinine 0 mg/dL", "80 mol/L", "following factors", "a risk factor", "patients condition"]}
{"question": "A 44-year-old obese African-American male presents to clinic with complaints of 3 days of fatigue and dark urine. He has had several similar episodes since birth, all of which resolved spontaneously. He has a 5-year history of poorly controlled type II diabetes mellitus and was started on glipizide one week ago. Prior to the episode, he felt well without any upper respiratory or gastrointestinal symptoms. He predominantly eats fast food, although he tried a new Lebanese restaurant about one month ago. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Medication", "options": {"A": "Bacterial Infection", "B": "Food", "C": "Medication", "D": "Idiopathic"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old obese African-American male presents", "clinic", "complaints", "3 days", "fatigue", "dark urine", "several similar episodes", "birth", "resolved", "5 year history", "poorly controlled type II diabetes mellitus", "started", "glipizide one week", "episode", "felt well", "upper respiratory", "gastrointestinal symptoms", "eats fast food", "new Lebanese restaurant", "one month", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 32-year-old woman comes to the physician because of fatigue and joint pain for the past 4 months. Examination shows erythema with scaling on both cheeks that spares the nasolabial folds and two 1-cm ulcers in the oral cavity. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Decreased lymphocyte count", "options": {"A": "Decreased lymphocyte count", "B": "Increased platelet count", "C": "Increased prothrombin time", "D": "Decreased gamma globulin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "fatigue", "joint pain", "past", "months", "Examination shows erythema", "scaling", "cheeks", "nasolabial folds", "two", "ulcers", "oral cavity", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "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?", "answer": "Increase in capillary pressure", "options": {"A": "Increase in capillary pressure", "B": "Decrease in plasma proteins", "C": "Increase in capillary permeability", "D": "Increase in interstitial fluid pressure"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["66 year old male", "history of myocardial infarction presents", "primary care office", "complaints", "dyspnea", "exertion", "swollen feet", "ankles", "exam", "note", "elevated", "2", "pitting edema of bilateral lower extremities", "most likely explanation", "patient's lower extremity edema"]}
{"question": "A 49-year-old man comes to the physician for a routine health maintenance examination. He feels well and has no history of serious illness. He has smoked one pack of cigarettes daily for the past 25 years and drinks two to three glasses of wine weekly. This patient should be counseled about increased risk for which of the following conditions?", "answer": "Pancreatic adenocarcinoma", "options": {"A": "Pancreatic adenocarcinoma", "B": "Esophageal varices", "C": "Porcelain gallbladder", "D": "Hepatic steatosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "routine health maintenance examination", "feels well", "history", "serious illness", "smoked one pack", "cigarettes daily", "past", "years", "drinks two", "three glasses", "wine weekly", "patient", "counseled", "increased risk", "following conditions"]}
{"question": "A 40-year-old woman comes to the physician because of a 6-month history of difficulty sleeping and fatigue. Menses occur at irregular 35- to 50-day intervals and last 3–7 days. Her last menstrual period was 5 weeks ago. She has had an unintentional 10-kg (22-lb) weight gain over this period. She also reports decreased sexual desire and increased hair growth on her face and arms. There is no personal or family history of serious illness. She appears lethargic. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 150/90 mm Hg. Physical examination shows central obesity, increased pigmented hair over the chin and upper lip, and purple stretch marks on the abdomen. She has a prominent hump of fat over the base of the dorsum of her neck and decreased proximal muscle tone and strength. Serum studies show:\nNa+ 154 mEq/L\nK+ 2.8 mEq/L\nCl- 103 mEq/L\nHCO3- 30 mEq/L\nCreatinine 0.9 mg/dL\nGlucose 236 mg/dL\nACTH 2 pg/mL (N = 7–50)\nWhich of the following is the most appropriate treatment for this patient?\"", "answer": "Adrenalectomy", "options": {"A": "Adrenalectomy", "B": "Polychemotherapy and radiation therapy", "C": "Transsphenoidal hypophysectomy", "D": "Partial nephrectomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["40 year old woman", "physician", "month history", "difficulty sleeping", "fatigue", "Menses occur", "irregular 35", "50 day intervals", "last", "days", "last menstrual period", "5 weeks", "unintentional 10 kg", "weight gain", "period", "reports decreased sexual desire", "increased hair growth", "face", "arms", "personal", "family history", "serious illness", "appears lethargic", "temperature", "98", "pulse", "80 min", "blood pressure", "90 mm Hg", "Physical examination shows central obesity", "increased pigmented hair", "chin", "upper lip", "purple stretch marks", "abdomen", "prominent", "fat", "the base of", "dorsum", "neck", "decreased proximal muscle tone", "strength", "Serum studies show", "Na", "mEq/L K", "Cl", "HCO3", "30", "Creatinine 0.9 mg dL Glucose", "dL ACTH", "mL", "N", "750", "following", "most appropriate", "patient"]}
{"question": "A scientist observes a myocyte beating in cell culture. Which step is the most direct necessary component of relaxation for this cell?", "answer": "Efflux of calcium ions", "options": {"A": "Influx of sodium ions", "B": "Influx of calcium ions from the sacroplasmic reticulum", "C": "Influx of calcium ions from outside the myocyte", "D": "Efflux of calcium ions"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["scientist observes", "myocyte beating", "cell culture", "step", "most direct", "component", "relaxation", "cell"]}
{"question": "Two days after admission to the hospital for treatment of acute myelogenous leukemia, a 35-year-old man develops nausea, vomiting, fatigue, and muscle cramps. He has a history of diet-controlled type 2 diabetes mellitus. He has smoked one-half pack of cigarettes daily for 15 years and reports occasionally using marijuana. His temperature is 38.7°C (101.1°F), pulse is 85/min, respirations are 25/min, and blood pressure is 110/65 mm Hg. Laboratory studies show:\nLeukocyte count 16,000/mm3\nHemoglobin 13.4 g/dL\nPlatelet count 180,000/mm3\nSerum\nNa+ 134 mEq/L\nK+ 5.9 mEq/L\nCl- 101 mEq/L\nHCO3- 24 mEq/L\nUrea nitrogen 27 mg/dL\nUric acid 11.2 mg/dL\nCreatinine 2.2 mg/dL\nGlucose 134 mg/dL\nCa2+ 6.8 mg/dL\nMg2+ 1.8 g/dL\nPhosphorus 8.9 mg/dL\nWhich of the following would have been most effective in preventing this patient's current symptoms?\"", "answer": "Intravenous hydration", "options": {"A": "Urine alkalinization", "B": "Rasburicase", "C": "Allopurinol", "D": "Intravenous hydration"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Two days", "admission", "hospital", "treatment", "acute myelogenous leukemia", "35 year old man", "nausea", "vomiting", "fatigue", "muscle cramps", "history of diet-controlled type 2 diabetes mellitus", "smoked one half pack", "cigarettes daily", "years", "reports occasionally using marijuana", "temperature", "pulse", "85 min", "respirations", "min", "blood pressure", "65 mm Hg", "Laboratory studies show", "g", "Serum", "Urea", "mg", "mg", "Creatinine", "g", "following", "most effective", "preventing", "patient", "urrent  ymptoms?"]}
{"question": "The menses are 4 weeks overdue in a 23-year-old sexually active woman, thus she is scheduled for an ultrasound examination. The result is shown in the exhibit. What is the function of the structure marked with the green arrow?", "answer": "Embryonic hematopoiesis", "options": {"A": "Removal of nitrogenous waste", "B": "Embryonic hematopoiesis", "C": "Production of amniotic fluid", "D": "Gas exchange"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["menses", "4 weeks", "23 year old sexually active woman", "scheduled", "ultrasound examination", "result", "shown", "exhibit", "function", "structure marked", "green arrow"]}
{"question": "A 49-year-old man comes to the physician because he has had multiple falls and multiple episodes of dizziness over the past 6 weeks. There is no personal or family history of serious illness. He drinks one pint of rum daily. He works as a foreman in a factory that produces industrial solvents. He is alert and oriented to time, place, and person. His temperature is 36.7°C (98.1°F), pulse is 88/min, and blood pressure is 108/70 mm Hg. Examination shows a wide-based gait. The patient is unable to stand with his feet together without support. There is a coarse tremor of the hands when he is asked to grab a pen. Muscle strength and tone are normal in all extremities. Sensation to pain, vibration, and position is intact bilaterally. Rapid alternating movements of the hands is impaired. Mental status examination shows no abnormalities. Which of the following is the most likely cause of this patient's condition?", "answer": "Cerebellar degeneration", "options": {"A": "Korsakoff syndrome", "B": "Methanol poisoning", "C": "Cerebellar degeneration", "D": "Wernicke's encephalopathy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "multiple falls", "multiple episodes of dizziness", "past", "weeks", "personal", "family history", "serious illness", "drinks one pint", "rum daily", "works", "foreman", "factory", "industrial solvents", "alert", "oriented to time", "place", "person", "temperature", "36", "98", "pulse", "88 min", "blood pressure", "70 mm Hg", "Examination shows", "wide-based gait", "patient", "unable to stand", "feet together", "support", "coarse tremor of", "hands", "to grab", "pen", "Muscle strength", "tone", "normal", "extremities", "Sensation", "pain", "vibration", "position", "intact", "Rapid alternating movements", "hands", "impaired", "Mental shows", "abnormalities", "following", "most likely cause", "patient's condition"]}
{"question": "A 7-year-old girl is brought to the physician by her mother for a well-child examination. The mother reports that she had her first menstrual period 1 week ago. She has no history of serious illness. Immunizations are up-to-date. Physical examination shows Tanner stage 3 breast development and pubic hair. Without treatment, this patient is at greatest risk for which of the following as an adult?", "answer": "Short stature", "options": {"A": "Delayed skeletal maturity", "B": "Short stature", "C": "Genu varum", "D": "Coarse facial features"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old girl", "brought", "physician", "mother", "well", "mother reports", "first menstrual period", "week", "history of serious illness", "Immunizations", "date", "Physical examination shows Tanner stage 3 breast development", "pubic hair", "treatment", "patient", "greatest risk", "following", "adult"]}
{"question": "A 67-year-old man presents to his primary care physician for a follow up appointment. He was released from the hospital 1 week ago for an appropriately managed ST-elevation myocardial infarction (STEMI); however, he has not filled any of his prescriptions and did not attend his follow up appointment as scheduled. The patient has a past medical history of hypertension and peripheral vascular disease. His temperature is 97.5°F (36.4°C), blood pressure is 167/118 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for jugular venous distention and bilateral lower extremity pitting edema. Echocardiography demonstrates an ejection fraction of 55%. Which of the following medications will have the greatest mortality benefit in this patient?", "answer": "Metoprolol succinate", "options": {"A": "Atenolol", "B": "Lisinopril", "C": "Metoprolol succinate", "D": "Propranolol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "primary care physician", "follow up appointment", "released", "hospital 1 week", "managed ST-elevation myocardial infarction", "not filled", "prescriptions", "not attend", "follow up appointment", "scheduled", "patient", "past medical", "peripheral vascular disease", "temperature", "97", "36 4C", "blood pressure", "mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "99", "room air", "Physical exam", "notable", "jugular venous distention", "bilateral lower extremity pitting edema", "Echocardiography demonstrates", "ejection fraction of 55", "following medications", "greatest mortality benefit", "patient"]}
{"question": "A 61-year-old man comes to the emergency department because of a 2-day history of a productive cough and worsening shortness of breath. He has had frequent episodes of a productive cough over the past 3 years. He had smoked 2 packs of cigarettes daily for 30 years but quit 1 year ago. He appears distressed. Pulse oximetry on room air shows an oxygen saturation of 91%. Chest auscultation reveals diffuse wheezes and coarse crackles. A chest x-ray shows increased lung lucency bilaterally and flattening of the diaphragm. Which of the following is the most appropriate initial pharmacotherapy?", "answer": "Prednisone and albuterol", "options": {"A": "Prednisone and albuterol", "B": "Albuterol and montelukast", "C": "Prednisone and tiotropium", "D": "Albuterol and theophylline"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["61 year old man", "emergency department", "2-day history", "productive cough", "worsening shortness of breath", "frequent episodes of", "productive cough", "past", "years", "smoked 2 packs", "cigarettes daily", "30 years", "quit", "year", "appears distressed", "Pulse oximetry", "room air shows", "oxygen saturation", "Chest auscultation reveals diffuse wheezes", "coarse crackles", "chest x-ray shows increased lung", "flattening", "diaphragm", "following", "most appropriate initial pharmacotherapy"]}
{"question": "An investigator is studying cellular regeneration of epithelial cells. She has obtained a tissue sample from a normal thyroid gland for histopathologic examination. It shows follicles lined by a single layer of cube-like cells with large central nuclei. Which of the following parts of the female reproductive tract is also lined by this type of epithelium?", "answer": "Ovaries", "options": {"A": "Ovaries", "B": "Vagina", "C": "Fallopian tubes", "D": "Vulva"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["investigator", "studying cellular regeneration", "epithelial cells", "obtained", "tissue sample", "normal thyroid gland", "histopathologic examination", "shows follicles lined", "single layer", "cube", "cells", "large central nuclei", "following parts", "female reproductive tract", "lined", "type of epithelium"]}
{"question": "A 22-year-old woman comes to the physician for a routine health examination. She feels well but asks for advice about smoking cessation. She has smoked one pack of cigarettes daily for 7 years. She has tried to quit several times without success. During the previous attempts, she has been extremely nervous and also gained weight. She has also tried nicotine lozenges but stopped taking them because of severe headaches and insomnia. She has bulimia nervosa. She takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 68 kg (150 lb); BMI is 24 kg/m2. Physical and neurologic examinations show no other abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Varenicline", "options": {"A": "Diazepam", "B": "Nicotine patch", "C": "Varenicline", "D": "Motivational interviewing"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "routine health examination", "feels well", "advice", "smoking cessation", "smoked one pack", "cigarettes daily", "years", "to quit several times", "success", "previous attempts", "extremely nervous", "gained weight", "nicotine lozenges", "stopped", "of severe headaches", "insomnia", "bulimia nervosa", "takes", "medications", "5 ft 6", "tall", "68 kg", "BMI", "kg/m2", "Physical", "neurologic examinations show", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A hospitalized 34-year-old man with severe diarrhea and bloating for 1 month is diagnosed with celiac disease based on serology and duodenal biopsy. He has no history of any serious illnesses and takes no medications. He has no history of recent travel. His vital signs are within normal limits. Physical examination is unremarkable. At discharge from the hospital, he is given complete instructions for a strict gluten-free diet. Which of the following is the most appropriate recommendation for the temporary control of the severe diarrhea and bloating?", "answer": "Avoiding all dairy products", "options": {"A": "Avoiding all dairy products", "B": "Diphenoxylate", "C": "Prednisone", "D": "Restriction of soy products"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["hospitalized", "year old man", "severe diarrhea", "bloating", "month", "diagnosed", "celiac disease based", "serology", "duodenal biopsy", "history", "serious illnesses", "takes", "medications", "history of recent travel", "vital signs", "normal", "Physical examination", "unremarkable", "discharge from", "hospital", "given complete instructions", "gluten-free diet", "following", "most appropriate recommendation", "temporary control", "severe diarrhea", "bloating"]}
{"question": "A 70-year-old man presents to the Emergency Department after 3 days of shortness of breath, orthopnea, and lower limb edema. His personal history is significant for a myocardial infarction 6 years ago that required revascularization and hypertension. His medication consists of simvastatin and lisinopril.  In the ED, he has a blood pressure of 100/80 mm Hg, a pulse of 88/min, a respiratory rate of 28/min, and a temperature of 36.5°C (97.7°F). On physical examination, he has jugular vein distention, displaced point of maximal impulse (PMI), an S4-gallop, a holosystolic murmur, and 2+ pitting edema up to the mid calf.  He is started on furosemide, carvedilol, and oxygen therapy. After 6-hours of continued therapy, his blood pressure remains low, and his serum creatinine is found to be 1.9 mg/dL. Which of the following test would be more useful to differentiate between prerenal and intrinsic kidney disease?", "answer": "Fractional excretion of urea (FEUrea)", "options": {"A": "Sulfosalicylic acid test", "B": "Urine sodium content", "C": "Fractional excretion of urea (FEUrea)", "D": "Nitrates in urine"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man presents", "Emergency Department", "3 days of shortness", "breath", "orthopnea", "lower limb edema", "personal history", "significant", "myocardial infarction", "years", "required revascularization", "hypertension", "medication consists", "simvastatin", "lisinopril", "ED", "blood pressure", "100 80 mm Hg", "pulse", "88 min", "respiratory rate", "min", "temperature", "36", "97", "physical examination", "jugular vein distention", "displaced point", "maximal impulse", "S4-gallop", "holosystolic murmur", "2", "pitting edema", "calf", "started", "furosemide", "carvedilol", "oxygen therapy", "6-hours", "continued therapy", "blood pressure", "low", "serum creatinine", "found to", "1.9 mg/dL", "following test", "more useful to differentiate", "prerenal", "intrinsic kidney disease"]}
{"question": "A 26-year-old Caucasian woman is admitted to the emergency department after 4 days of fever, malaise, vomiting, and nausea for which she has been taking ibuprofen and diclofenac. She has also noticed a decrease in urination. Her family and past medical history are unremarkable. Her temperature is 38.2°C (100.7°F), blood pressure is 118/76 mm Hg, heart rate is 74/min, and respiratory rate is 15/min. Upon physical examination, her mucous membranes are moist and she has no abdominal tenderness. Four hours after admission, she has a urinary output < 0.3 mL/kg/h and laboratory tests significant for the following:\nDifferential blood count\nWhite blood cells 8.1 x 109/L\nNeutrophils 4.8 x 109/L\nLymphocytes 2.1 x 109/L\nEosinophils 0.9 x 109/L\nMonocytes 0.3 x 109/L\nBasophils 0.04 x 109/L\n  Serum creatinine (SCr) 1.9 mg/dL\nBlood urea nitrogen (BUN) 25 mg/dL\nNa+ 135 mEq/L\nK+ 5.4 mEq/L\nCl- 106 mEq/L\nUrine dipstick\nUrine density 1.010\npH 6.2\nRed blood cells per field of high power 2\nWBC casts Present\nWhich of the following skin manifestations would you also expect to find in this patient?", "answer": "Diffuse maculopapular rash", "options": {"A": "Janeway lesions", "B": "Diffuse maculopapular rash", "C": "Malar rash", "D": "Erythema nodosum"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old Caucasian woman", "admitted", "emergency department", "4 days", "fever", "malaise", "vomiting", "nausea", "taking ibuprofen", "diclofenac", "decrease", "urination", "family", "past medical history", "unremarkable", "temperature", "100", "blood pressure", "76 mm Hg", "heart rate", "74 min", "respiratory rate", "min", "physical examination", "mucous membranes", "moist", "abdominal tenderness", "Four hours", "admission", "urinary output", "0.3 mL/kg/h", "laboratory tests significant", "following", "Differential", "White blood cells 8", "4 8", "0", "3", "04", "Serum creatinine", "SCr", "9 mg/dL", "nitrogen", "L", "5", "Urine", "density", "Red blood cells", "field", "high power", "WBC casts Present", "following skin manifestations", "to find", "patient"]}
{"question": "A 59-year-old woman presents to the outpatient clinic for worsening symptoms of congestive heart failure. She states that while she used to be able to go for short walks, she is no longer able to do so. Now, even simple tasks like getting ready in the morning have become burdensome for her. When she gets tired, sitting down helps to alleviate her symptoms. Her blood pressure is 136/92 mm Hg and heart rate is 76/min. On physical examination, she has regular heart sounds but does have 1+ pitting edema to her bilateral lower extremities. What is her New York Heart Association Functional Classification for congestive heart failure?", "answer": "New York Heart Association Class III", "options": {"A": " New York Heart Association Class IIa", "B": "New York Heart Association Class IIb", "C": "New York Heart Association Class III", "D": "New York Heart Association Class IV"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["59 year old woman presents", "outpatient clinic", "worsening symptoms", "congestive heart failure", "states", "used to", "able to go", "short walks", "longer able", "Now", "simple tasks", "getting ready", "morning", "gets tired", "sitting", "helps to", "symptoms", "blood pressure", "mm Hg", "heart rate", "76 min", "physical examination", "regular heart sounds", "1", "pitting edema", "bilateral", "New York Heart Association", "Functional Classification", "congestive", "failure"]}
{"question": "A 36-year-old woman comes to the physician for intermittent stabbing face pain. The pain typically occurs in waves of several individual episodes lasting about one second. It is bilateral, but rarely occurs on both sides simultaneously. Touching her face or brushing her teeth can trigger an attack. Four months ago, she had an episode of weakness in her right arm that lasted for about a week. Family history is notable for migrainous headaches in her mother and brother. Vital signs are within normal limits. There is decreased sensation in the V2 and V3 distribution of her face bilaterally. Muscle strength is 3/5 in the left upper extremity and 5/5 in the right upper extremity. There is spasticity of the lower extremities with sustained clonus. Further evaluation is most likely going to reveal which of the following findings?", "answer": "Multiple periventricular sclerotic plaques", "options": {"A": "Multiple periventricular sclerotic plaques", "B": "Erythematous papules in the V2/V3 nerve distribution", "C": "Photophobia and phonophobia", "D": "Rhinorrhea, lacrimination, and ptosis"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["36 year old woman", "physician", "intermittent stabbing face", "pain", "occurs", "waves of", "individual episodes lasting", "one second", "bilateral", "rarely occurs", "sides simultaneously", "Touching", "face", "brushing", "teeth", "trigger", "attack", "Four months", "episode of weakness", "right arm", "lasted", "week", "Family history", "notable", "headaches", "mother", "brother", "Vital signs", "normal limits", "decreased sensation", "V2", "V3 distribution of", "face", "Muscle strength", "3/5", "left upper extremity", "5/5", "right upper extremity", "spasticity of", "lower extremities", "sustained clonus", "Further evaluation", "most likely", "to reveal", "following findings"]}
{"question": "A 23-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician for a routine prenatal examination. Her previous pregnancy was uncomplicated and she gave birth to a healthy boy. Her blood group is A, Rh-negative. The father's blood group is B, Rh-positive. Administration of which of the following is most appropriate at this time?", "answer": "Anti-D IgG", "options": {"A": "Anti-A IgG", "B": "Anti-D IgG", "C": "Anti-B IgG", "D": "Anti-D IgM"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old woman", "gravida 2", "para 1", "weeks", "gestation", "physician", "routine prenatal examination", "previous pregnancy", "uncomplicated", "gave birth", "healthy boy", "blood group", "Rh-negative", "father's blood group", "Rh-positive", "Administration", "following", "most appropriate", "time"]}
{"question": "A 61-year-old man presents to the clinic with complaints of excessive thirst, frequent urination, and partial visual loss in both eyes for 1 day. His family history is significant for type 2 diabetes mellitus in his mother and cousin. His weight is 112 kg ( 246.9 lb), height 187 cm (6 ft 1 in), blood pressure: 150/90 mm Hg, heart rate: 89/min, respiratory rate: 14/min, and temperature: 36.7℃ (98.4℉). The physical examination is significant for dry skin, a pustular rash over the patient’s shoulders and back, an accentuated second heart sound (S2) best heard in the second intercostal space at the right sternal border, and distal loss of vibration sensitivity in both feet. A fundoscopic examination shows small red dots in the superficial retinal layers suggestive of microaneurysms. The HbA1c is 9% and the urinalysis shows the following:\nColor Pale yellow (light/pale-to-dark/deep amber)\nClarity Cloudy\npH 6.6\nSpecific gravity 1.010\nGlucose 199 mg/dl\nKetones None\nNitrites Negative\nLeukocyte esterase Negative\nBilirubin Negative\nUrinary bilirubin Traces\nRed blood cells 3 RBCs\nProtein 120 mg/d\nRBCs ≤ 2 RBCs/hpf\nWBCs 22 WBCs/hpf\nEpithelial cells 27 squamous epithelial cells/hpf\nCasts 5 hyaline casts/lpf\nCrystals Occasional\nBacteria None\nYeast Present\nWhich of the following statements best describes the cause of this patient’s glucosuria?", "answer": "Secondary active transporters fail to completely reabsorb glucose in the renal tubules", "options": {"A": "There is a disruption of primary active transport of glucose in the proximal renal tubules", "B": "Secondary active transporters fail to completely reabsorb glucose in the renal tubules", "C": "There is a disruption of passive transport of the glucose in the proximal renal tubules", "D": "Glucosuria results from increased glomerular filtration rate"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["61 year old man presents", "clinic", "complaints", "excessive thirst", "frequent urination", "partial visual", "eyes", "1 day", "family history", "significant", "type 2 diabetes mellitus", "mother", "cousin", "weight", "kg", "height", "ft", "blood pressure", "90 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature", "36", "98", "physical examination", "significant", "dry skin", "pustular rash", "patients shoulders", "back", "accentuated second heart sound", "S2", "best heard", "second intercostal space", "right sternal border", "distal loss", "vibration sensitivity", "feet", "fundoscopic examination shows small red dots", "superficial retinal layers suggestive of microaneurysms", "urinalysis shows", "following", "Color Pale", "light pale", "dark deep amber", "Clarity Cloudy pH", "Specific gravity", "Glucose", "mg/dl Ketones", "Nitrites Negative Leukocyte esterase", "Bilirubin", "Urinary", "Traces Red blood cells", "RBCs Protein", "mg", "Epithelial", "squamous epithelial cells", "Casts 5 hyaline casts lpf Crystals Occasional Bacteria", "Yeast Present", "following statements best", "cause", "patients glucosuria"]}
{"question": "A 65-year-old male presents to his primary care physician for stiffness in his arm. He states that he has been having trouble combing his hair and reaching objects that are high on the shelf. The patient has a past medical history of diabetes mellitus type II, obesity, and hypertension. His current medications include metformin, insulin, lisinopril, and hydrochlorothiazide. The patient admits to leading a sedentary life in which he tends to stay home and watch television. He does not engage in any physical or strenuous activity. On physical exam the patient has decreased passive and active range of motion of his shoulder. Strength of the patient's upper extremity is 4/5. Which of the following is the most likely diagnosis?", "answer": "Adhesive capsulitis", "options": {"A": "Rotator cuff impingement", "B": "Adhesive capsulitis", "C": "Glenohumeral osteoarthritis", "D": "Subacromial bursitis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old male presents", "primary care physician", "stiffness", "arm", "states", "combing", "hair", "reaching objects", "high", "patient", "past medical history of diabetes mellitus type II", "obesity", "hypertension", "current medications include metformin", "insulin", "lisinopril", "hydrochlorothiazide", "patient admits", "leading", "sedentary life", "to", "home", "watch television", "not", "physical", "strenuous activity", "physical exam", "patient", "decreased passive", "active range of motion of", "shoulder", "Strength", "patient's upper extremity", "4/5", "following", "most likely diagnosis"]}
{"question": "A 52-year-old man presents to the clinic with a headache and dizziness for the past month. The patient reports that about 4 weeks ago he developed a “nagging” headache. He thought he had a cold, so he tried over the counter ibuprofen that provided only mild and temporary relief. Recently, he also started feeling dizzy and nauseous, which only resolves when he steps outside to shovel the snow. The patient’s medical history is significant for hypertension, type II diabetes mellitus, and asthma. His medications include amlodipine, metformin, glimepiride, and a fluticasone/salmeterol inhaler. The patient has been living at his upstate cabin for the past 5 weeks but denies other recent travel. He denies smoking tobacco or illicit drug use. The patient’s temperature is 99°F (37.2°C), blood pressure is 130/78 mmHg, pulse is 72/min, and respirations are 16/min with an oxygen saturation of 98% on room air. The patient is currently asymptomatic while sitting in the office, and physical examination is unremarkable. Labs are drawn, as shown below:\n\nHemoglobin: 20 g/dL\nHematocrit: 60%\nLeukocyte count: 10,050 cells/mm^3 with normal differential\nPlatelet count: 350,000/mm^3\n\nWhich of the following underlies the patient’s most likely diagnosis?", "answer": "Toxic exposure", "options": {"A": "Medication side effect", "B": "Myeloproliferative neoplasm", "C": "Neuronal hyperexcitability", "D": "Toxic exposure"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "clinic", "headache", "dizziness", "past month", "patient reports", "4 weeks", "nagging headache", "thought", "cold", "over the counter ibuprofen", "provided only mild", "temporary relief", "Recently", "started feeling dizzy", "nauseous", "only resolves", "steps outside to", "snow", "patients medical history", "significant", "hypertension", "type II diabetes mellitus", "asthma", "medications include amlodipine", "metformin", "glimepiride", "fluticasone/salmeterol inhaler", "patient", "living", "past", "weeks", "denies", "recent travel", "denies smoking tobacco", "illicit drug use", "patients temperature", "blood pressure", "mmHg", "pulse", "72 min", "respirations", "16 min", "oxygen saturation", "98", "room air", "patient", "currently asymptomatic", "sitting", "office", "physical examination", "unremarkable", "Labs", "drawn", "shown", "Hemoglobin", "20 g/dL Hematocrit", "60", "Leukocyte count", "10", "cells mm 3", "normal differential Platelet count", "350", "mm", "following", "patients", "likely diagnosis"]}
{"question": "A 20-year-old woman comes to the clinic for her first follow-up visit after being diagnosed with bipolar I disorder 1-month ago. At that time, she was acutely severely manic and was brought to the emergency department by her concerned boyfriend. She was started on lithium, and after subsequent improvement, she was discharged. A week after discharge, the patient forgot to take her medication for a few days and quickly began to manifest manic symptoms again which required brought her to the emergency department again. Since then, she has been compliant with her medications and currently has no significant complaints. Which of the following recommendations would be most helpful in minimizing the risk to the fetus in this patient?", "answer": "Adjust dosage of medication throughout the pregnancy", "options": {"A": "Adjust dosage of medication throughout the pregnancy", "B": "Supplement all patients with 5mg of daily folic acid", "C": "Low-dose polytherapy is preferred over monotherapy", "D": "Switch to valproate as it has safest pregnancy profile"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["20 year old woman", "clinic", "first follow-up visit", "diagnosed", "bipolar I disorder 1 month", "time", "severely manic", "brought", "emergency department", "boyfriend", "started", "lithium", "subsequent improvement", "discharged", "week", "discharge", "patient forgot to take", "medication", "days", "began to manifest manic symptoms", "required brought", "emergency department", "then", "compliant", "medications", "currently", "significant complaints", "following recommendations", "most helpful", "risk", "fetus", "patient"]}
{"question": "A 19-year-old female presents to the emergency room with 6 days of lower abdominal pain. She states that her symptoms have progressed and she now feels feverish as well. She also notes an episode of nonbloody diarrhea 2 days ago and has been increasingly nauseous. While being evaluated in the emergency room, she vomits three times. The patient has no significant past medical history but was recently treated with ciprofloxacin for an uncomplicated urinary tract infection. She also notes irregular periods, with a last menstrual period 6 weeks ago. She is a college student who has had 3 sexual partners in the last year with inconsistent use of barrier protection. Her temperature is 100.5°C (38.1°F), blood pressure is 102/68 mmHg, pulse is 97/min, and respirations are 14/min. On exam, the patient is noticeably uncomfortable. There is marked tenderness to palpation in the suprapubic region and right lower quadrant, with voluntary guarding but no rebound. Pelvic exam shows moderate purulent discharge in the vaginal vault, cervical motion tenderness, and a tender adnexal mass on the right side. Which of the following is the best next step in treating this patient’s condition?", "answer": "Intravenous cefotetan and doxycycline with inpatient admission", "options": {"A": "Intramuscular ceftriaxone and oral doxycycline with outpatient follow-up", "B": "Intravenous cefotetan and doxycycline with inpatient admission", "C": "Oral vancomycin with outpatient follow-up", "D": "Methotrexate with outpatient follow-up"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female presents", "emergency room", "6 days", "lower abdominal pain", "states", "symptoms", "progressed", "now feels feverish", "well", "notes", "episode of", "diarrhea 2 days", "nauseous", "evaluated", "emergency room", "vomits three times", "patient", "significant past medical history", "recently treated with ciprofloxacin", "uncomplicated urinary tract infection", "notes irregular periods", "last menstrual period", "weeks", "college student", "3 sexual partners", "year", "inconsistent use of barrier protection", "temperature", "100", "blood pressure", "68 mmHg", "pulse", "97 min", "respirations", "min", "exam", "patient", "marked tenderness", "palpation", "suprapubic region", "right lower quadrant", "voluntary guarding", "Pelvic exam shows moderate purulent discharge", "vaginal vault", "cervical motion tenderness", "tender adnexal mass", "right side", "following", "best next step", "treating", "patients condition"]}
{"question": "A 72-year-old man with hypertension and type 2 diabetes mellitus is admitted to the hospital for the evaluation of breathlessness and fatigue. His pulse is 100/min, and blood pressure is 90/60 mm Hg. Further evaluation shows a systemic vascular resistance of 35 mm Hg × min/L with an end-systolic volume of 80 mL. Which of the following describes the ejection fraction in this patient?", "answer": "20%", "options": {"A": "30%", "B": "15%", "C": "25%", "D": "20%"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old man", "hypertension", "type 2 diabetes mellitus", "admitted", "hospital", "evaluation", "breathlessness", "fatigue", "pulse", "100 min", "blood pressure", "90 60 mm Hg", "Further evaluation shows", "systemic vascular resistance", "35 mm Hg", "min/L", "end-systolic volume", "80 mL", "following", "ejection fraction", "patient"]}
{"question": "A 24-year-old woman presents to the office for evaluation of intermittent vertigo for the past 2 days. She complains of vomiting and complete hearing loss in her left ear. The patient believes she had an ear infection in the same ear but never sought out treatment. She has a past medical history of uterine fibroids. She takes mifepristone daily to reduce the size of the fibroids. Her blood pressure is 114/72 mm Hg, the heart rate is 68/min, the respiratory rate is 12/min, and the temperature is 36.8°C (98.2°F). The patient appears pale and in mild distress. Otoscopy reveals a suppurative, erythematous, bulging tympanic membrane. The tympanic membrane is observed to be immobile as confirmed by the pneumatoscope. Pure-tone audiometry testing reveals hearing loss across all frequencies in the left ear. Heart auscultation is without murmurs. Lungs are clear to auscultation bilaterally. Nystagmus is positive to the right. MRI of the brain does not reveal a tumor or abscess. Her physician orders a complete blood count with differential and comprehensive metabolic panel, which show:\nHemoglobin 14.5 gm/dL\nHematocrit 43.2 %\nWhite blood cells 14,500 /mm3\nPlatelets 312,000/mm3\nNeutrophil 81.6%\nLymphocyte 15.2%\nMonocyte 1.4%\nEosinophil 1.2%\nBasophil 0.6%\nSerum Na+ 138 mEq/L\nK+ 4.3 mEq/L\nCl- 108 mmol/L\nBUN 12 mg/dL\nCreatinine 0.8 mg/dL\nWhich of the following is the most appropriate antibiotic choice for this patient?", "answer": "Amoxicillin", "options": {"A": "Cefepime", "B": "Cefotaxime", "C": "Amoxicillin", "D": "Cephalexin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "office", "evaluation", "intermittent vertigo", "past 2 days", "vomiting", "complete hearing loss in", "left ear", "patient", "ear infection", "same", "never", "out treatment", "past medical uterine fibroids", "takes mifepristone daily to", "size", "fibroids", "blood pressure", "72 mm Hg", "heart rate", "68 min", "respiratory rate", "min", "temperature", "36", "98", "patient appears pale", "mild distress", "Otoscopy reveals", "suppurative", "erythematous", "bulging tympanic membrane", "tympanic membrane", "observed to", "immobile", "confirmed by", "Pure-tone audiometry testing reveals hearing loss", "frequencies", "left ear", "Heart auscultation", "murmurs", "Lungs", "clear", "auscultation", "Nystagmus", "positive", "right", "MRI of", "brain", "not reveal", "tumor", "abscess", "physician orders", "complete blood count", "differential", "comprehensive metabolic panel", "show", "Hemoglobin", "Hematocrit", "White blood cells", "15", "4", "0", "3", "mg", "mg", "following", "most appropriate antibiotic choice", "patient"]}
{"question": "A 52-year-old woman presents to the emergency department due to severe pain of her first metatarsophalangeal (MTP) joint. This pain started acutely, and she describes the pain as sharp. Her medical history is significant for obesity, hypertension, inflammatory bowel disease, and extensive alcohol use. She takes a number of medications but does not remember what they are. On physical exam, her right first MTP joint appears warm, swollen, erythematous, and exquisitely painful to the touch. After resolution of this acute episode, the patient is started on a drug to prevent recurrence of the symptoms. One month later on follow-up, she is found to have pancytopenia. Which of the following describes the mechanism of the drug most likely prescribed in this case?", "answer": "Inhibitor of xanthine oxidase", "options": {"A": "Antibody to soluble factor", "B": "Inhibitor of microtubule polymerization", "C": "Inhibitor of proximal tubule reabsorption", "D": "Inhibitor of xanthine oxidase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department due to severe pain", "first metatarsophalangeal", "joint", "pain started", "pain", "sharp", "medical history", "significant", "obesity", "hypertension", "inflammatory bowel disease", "extensive alcohol use", "takes", "number of medications", "not remember", "physical exam", "right first MTP joint appears warm", "swollen", "erythematous", "painful", "touch", "resolution of", "acute episode", "patient", "started", "drug to prevent recurrence", "symptoms", "One month later", "follow-up", "found to", "pancytopenia", "following", "mechanism", "drug", "likely prescribed", "case"]}
{"question": "A 59-year-old man complains of chest pain that has been present for 4 hours on the 5th day of hospitalization for acute myocardial infarction. 5 days ago, he had a burning sensation in his chest and discomfort in his left shoulder. Upon initial presentation to the hospital’s emergency department, he was diagnosed with an ST-elevation myocardial infarction and treated with alteplase. He has been under close observation since then. The patient now describes discomfort in his chest and left shoulder, somewhat similar in nature to what initially brought him into the hospital. A pulse of 86/min, respiratory rate of 16/min, and a blood pressure of 146/90 mm Hg are observed. Auscultation of the chest reveals no abnormal findings. The patient’s ECG is difficult to interpret. Of the following laboratory tests, an abnormal result of which would have the most diagnostic utility?", "answer": "Creatine kinase (CK-MB)", "options": {"A": "Alkaline phosphatase", "B": "Creatine kinase (CK-MB)", "C": "Lactate dehydrogenase", "D": "Troponin T"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["59 year old man", "of chest pain", "present", "hours", "5th day", "hospitalization", "acute myocardial infarction", "days", "burning sensation", "chest", "discomfort", "left", "initial presentation", "hospitals emergency department", "diagnosed", "ST-elevation myocardial infarction", "treated with alteplase", "close observation", "then", "patient now", "discomfort in", "chest", "left shoulder", "somewhat similar", "nature", "initially brought", "hospital", "pulse", "min", "respiratory rate", "min", "blood pressure", "90 mm Hg", "observed", "Auscultation", "chest reveals", "abnormal findings", "patients ECG", "difficult to interpret", "following laboratory tests", "abnormal result", "most diagnostic utility"]}
{"question": "A 16-year-old girl comes to the emergency department because of left wrist pain and swelling for 5 hours. She fell on an outstretched hand while playing basketball. She ignored it initially as she thought it was just a bruise, but the pain and swelling worsened throughout the day. The analgesic spray she used did not provide adequate relief. There is no family history of serious illness. Her only medication is an oral contraceptive pill. Her immunizations are up-to-date. She appears anxious. Her temperature is 37.1°C (99°F), pulse is 88/min, and blood pressure is 118/72 mm Hg. Examination shows a swollen and tender left wrist; range of motion is limited. The anatomical snuffbox is tender to palpation. The grip strength of the left hand is decreased. The thumb can be opposed towards the other fingers. Finkelstein's test is negative. X-rays of the wrist shows no abnormalities. Which of the following is the most appropriate next best step in management?", "answer": "Thumb spica cast and repeat x-rays in 2 weeks", "options": {"A": "Corticosteroid injections", "B": "Thumb spica cast and repeat x-rays in 2 weeks", "C": "Rest, ice, and repeat x-rays in 2 weeks", "D": "Percutaneous pinning\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old girl", "emergency department", "left", "swelling", "hours", "fell", "hand", "playing basketball", "ignored", "initially", "thought", "bruise", "pain", "swelling worsened", "day", "analgesic spray", "used", "not provide adequate relief", "family history", "serious illness", "only medication", "oral contraceptive pill", "immunizations", "date", "appears anxious", "temperature", "pulse", "88 min", "blood pressure", "72 mm Hg", "Examination shows", "swollen", "tender left wrist", "range of motion", "limited", "anatomical snuffbox", "tender", "palpation", "grip strength", "left hand", "decreased", "thumb", "fingers", "Finkelstein's test", "negative", "X-rays of", "wrist shows", "abnormalities", "following", "most appropriate next best step", "management"]}
{"question": "A 46-year-old man comes to the physician with a 1-week history of yellowish discoloration of his eyes, generalized fatigue, and pruritus. He was diagnosed with ulcerative colitis 7 years ago. At the time of diagnosis, a pANCA test was also positive. Physical examination shows scleral icterus and multiple scratch marks on the trunk and extremities. Abdominal examination is unremarkable. Serum studies show a total bilirubin concentration of 3.2 mg/dL, direct bilirubin concentration of 2.5 mg/dL, and alkaline phosphatase level of 450 U/L. Magnetic resonance cholangiopancreatography shows focal areas of intrahepatic bile duct strictures alternating with areas of dilation. Histologic examination of a liver biopsy specimen is most likely to show which of the following findings?", "answer": "Periductal concentric scarring and fibrosis", "options": {"A": "Periductal concentric scarring and fibrosis", "B": "Periportal lymphocytic infiltration and piecemeal necrosis", "C": "Irregular ductal glands lined by atypical and pleomorphic cells", "D": "Ductopenia and fibrotic degeneration of periportal hepatocytes"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "physician", "1-week history", "discoloration", "eyes", "generalized fatigue", "pruritus", "diagnosed", "ulcerative colitis", "years", "time", "diagnosis", "pANCA test", "positive", "Physical examination shows scleral icterus", "multiple scratch marks", "trunk", "extremities", "Abdominal examination", "unremarkable", "Serum studies show", "total bilirubin concentration", "mg/dL", "direct", "2", "mg dL", "alkaline phosphatase level", "450 U/L", "Magnetic resonance cholangiopancreatography shows focal areas of intrahepatic bile duct strictures alternating", "areas of dilation", "Histologic examination", "liver biopsy specimen", "most likely to show", "following findings"]}
{"question": "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?", "answer": "Haemophilus ducreyi", "options": {"A": "Klebsiella granulomatis", "B": "Herpes simplex virus type 2", "C": "Haemophilus ducreyi", "D": "Treponema pallidum"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["29 year old woman presents", "primary care doctor", "lesion", "left labia", "first", "lesion", "days", "patient", "lesion", "painful", "swollen", "denies vaginal discharge", "past medical history", "notable", "mild intermittent asthma", "gout", "obesity", "uses", "albuterol inhaler as needed", "takes allopurinol", "5 sexual partners", "past year", "uses", "pull out method", "contraception", "a 10 pack-year smoking history", "drinks 10", "alcoholic beverages", "week", "exam", "ulcerated", "tender", "purulent ulcer", "left labia majora", "patient", "mild unilateral inguinal lymphadenopathy", "patient's condition", "most likely caused", "following pathogens"]}
{"question": "A 67-year-old man presents with feelings of nervousness and anxiety. He mentions that lately, he has been feeling increasingly restless and is unable to control feelings of nervousness pertaining to all his daily tasks. He noticed that these feelings were more prominent in the last 2 months but have been present on and off for the last year. On many occasions, his mind will be racing with thoughts that keep him up at night. During these moments, he finds his heart racing and feels light-headed and dizzy to the point of blacking out. He has also been experiencing back and neck pain with increased muscle tension in these areas. The patient reports no smoking or alcohol use but mentions that he had tried cocaine and heroin in his 20s and 30s. Which of the following would be the best course of treatment for this patient’s symptoms?", "answer": "Buspirone", "options": {"A": "Diazepam", "B": "Ramelteon", "C": "Buspirone", "D": "Alprazolam"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old man presents", "feelings of nervousness", "anxiety", "feeling", "restless", "unable to control feelings of nervousness", "daily tasks", "feelings", "more prominent", "months", "present", "year", "occasions", "mind", "racing", "thoughts", "keep", "night", "finds", "heart racing", "feels light-headed", "dizzy", "point", "blacking out", "experiencing back", "neck pain", "increased muscle tension", "areas", "patient reports", "smoking", "alcohol use", "cocaine", "heroin", "20s", "30s", "following", "best course", "treatment", "patients symptoms"]}
{"question": "Two hours after undergoing open cholecystectomy for complicated cholecystitis, a 48-year-old woman develops dizziness, lethargy, abdominal pain, and nausea. She has systemic lupus erythematosus and hypertension. Prior to hospitalization, her medications included nifedipine and prednisolone. Her pulse is 112/min and blood pressure is 90/64 mm Hg. Examination shows central obesity. The abdomen is soft and non-tender, and the laparoscopic incisions have no discharge. Her serum cortisol and serum ACTH are decreased. Which of the following additional findings is most likely in this patient?", "answer": "Hyponatremia", "options": {"A": "Normal anion gap metabolic acidosis", "B": "Hyperkalemia", "C": "Hyperglycemia", "D": "Hyponatremia"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["Two hours", "open cholecystectomy", "complicated cholecystitis", "48 year old woman", "dizziness", "lethargy", "abdominal pain", "nausea", "systemic lupus erythematosus", "hypertension", "hospitalization", "medications included nifedipine", "prednisolone", "pulse", "min", "blood pressure", "90 64 mm Hg", "Examination shows central obesity", "abdomen", "soft", "non-tender", "laparoscopic incisions", "discharge", "serum cortisol", "serum ACTH", "decreased", "following additional findings", "most likely", "patient"]}
{"question": "A 28-year-old woman, gravida 2, para 1, at 40 weeks of gestation is admitted to the hospital in active labor. The patient has attended many prenatal appointments and followed her physician's advice about screening for diseases, laboratory testing, diet, and exercise. Her pregnancy has been uncomplicated. She has no history of a serious illness. Her first child was delivered via normal vaginal delivery. Her vital signs are within normal limits. Cervical examination shows 100% effacement and 10 cm dilation. A cardiotocograph is shown. Which of the following is the most appropriate initial step in management?", "answer": "Reassurance", "options": {"A": "Amnioinfusion", "B": "Induced vaginal delivery", "C": "Reassurance", "D": "Repositioning"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "gravida 2", "para 1", "40 weeks of gestation", "admitted", "hospital", "active labor", "patient", "attended", "prenatal appointments", "followed", "physician's advice", "screening", "diseases", "laboratory testing", "diet", "exercise", "pregnancy", "uncomplicated", "history", "serious illness", "first child", "delivered", "normal vaginal", "vital signs", "normal limits", "Cervical examination shows 100", "effacement", "10", "dilation", "cardiotocograph", "shown", "following", "most appropriate initial step", "management"]}
{"question": "A 63-year-old female complains of weakness, light-headedness, palpitations, and soreness of the tongue. She has a past medical history of Hashimoto’s thyroiditis. Her hematocrit is 29%. On peripheral blood smear, you notice neutrophils with 7 lobes and large oval-shaped red blood cells. On physical exam, you notice the patient has decreased position sense and a loss in vibratory sensation in her lower extremities. Which of the following is most likely present in this patient?", "answer": "Anti-intrinsic factor antibodies", "options": {"A": "Atrophy of G cells", "B": "Anti-intrinsic factor antibodies", "C": "Decreased methylmalonic acid levels", "D": "Antithrombotic state"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["63 year old female", "weakness", "light-headedness", "palpitations", "soreness of", "tongue", "past medical Hashimotos thyroiditis", "hematocrit", "29", "peripheral blood smear", "neutrophils", "lobes", "large oval-shaped red blood cells", "physical exam", "patient", "decreased position sense", "loss", "sensation", "lower extremities", "following", "most likely present", "patient"]}
{"question": "A 45-year-old man presents to the doctor’s office with shortness of breath, cough, and fatigue for 3 days. This has been progressively worsening. He has a medical history significant for chronic obstructive pulmonary disease and osteoarthritis. He takes albuterol, ipratropium and aspirin. He smoked 2 and a half packs per day, and had done so for the past 26 years. After ceasing tobacco use for 1 year, he has recently begun smoking again. The blood pressure is 138/88 mm Hg, the respiratory rate is 12/min, the heart rate is 76/min, and the pulse oximetry is 87% on room air. On physical examination, the patient appears disoriented and is only somewhat comprehensible. The pupils are equal, round, and reactive to light with extraocular movements intact. Cranial nerves VII-XII also intact. The auscultation of the heart is absent of murmur, rubs, or gallops. The auscultation of the lungs demonstrate audible rales in the bases bilaterally. Which of the stages of change is the patient currently experiencing based on the clinical vignette?", "answer": "Relapse", "options": {"A": "Precontemplation", "B": "Contemplation", "C": "Maintenance", "D": "Relapse"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "doctors office", "shortness of breath", "cough", "fatigue", "3 days", "worsening", "medical history significant", "chronic obstructive pulmonary disease", "osteoarthritis", "takes albuterol", "ipratropium", "aspirin", "smoked 2", "half packs per day", "so", "past", "years", "ceasing tobacco use", "year", "recently begun smoking", "blood pressure", "88 mm Hg", "respiratory rate", "min", "heart rate", "76 min", "pulse oximetry", "87", "room air", "physical examination", "patient appears disoriented", "only somewhat", "pupils", "equal", "round", "reactive to light", "extraocular movements intact", "Cranial nerves VII XII", "intact", "auscultation of", "heart", "absent", "murmur", "rubs", "auscultation", "lungs", "rales", "bases", "of", "stages", "change", "patient currently experiencing based", "clinical"]}
{"question": "A 28-year-old man reports to his physician that he is having second thoughts about his long-term compatibility with his wife ever since they relocated to a new city. He admits that he has noticed himself flirting with some of the female co-workers at his new workplace. When he goes on a dinner date with his wife after work one evening, he accuses her of giving their waiter flirtatious looks and asks her whether she has been cheating on him or trying to spend time with other men. The man’s actions are most consistent with which of the following psychological defense mechanisms?", "answer": "Projection", "options": {"A": "Displacement", "B": "Dissociation", "C": "Projection", "D": "Repression"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man reports", "physician", "second thoughts", "long-term compatibility", "wife ever", "relocated", "new city", "admits", "female co workers", "new workplace", "goes", "dinner date", "wife", "work one evening", "giving", "waiter", "looks", "cheating", "to spend time", "men", "mans actions", "most consistent with", "following psychological defense mechanisms"]}
{"question": "A 25-year-old, G2P2L2 woman presents with a complaint of missed menstrual cycle for 4 weeks. Her previous menstrual cycles were regular, occurring every 28–35 days consistently. The patient does not have any other complaints currently. Her past medical history reveals two uncomplicated and normal vaginal deliveries at term. She has a 2-year-old boy and a 6-month-old girl. The patient and her partner use the withdrawal method for contraception. The urine pregnancy test result is positive. The patient returns to the clinic after 1 week expressing her desire to discontinue with the pregnancy and inquires about the possibility of an elective abortion. Which of the following procedures is the most appropriate for elective termination of pregnancy in this patient?", "answer": "Oral mifepristone + misoprostol", "options": {"A": "Dilatation and evacuation (D&E)", "B": "Oxytocin-induced labor", "C": "Manual uterine aspiration", "D": "Oral mifepristone + misoprostol"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old", "woman presents", "complaint", "missed menstrual cycle", "4 weeks", "previous menstrual cycles", "regular", "occurring", "days", "patient", "not", "complaints currently", "past medical history reveals two uncomplicated", "normal vaginal deliveries", "term", "2 year old boy", "month old girl", "patient", "partner use", "withdrawal method", "contraception", "urine", "positive", "patient returns", "clinic", "1 week", "desire", "discontinue", "pregnancy", "possibility", "elective abortion", "following procedures", "most appropriate", "elective termination of pregnancy", "patient"]}
{"question": "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?", "answer": "Seborrheic keratosis", "options": {"A": "Melanoma", "B": "Seborrheic keratosis", "C": "Acanthosis nigricans", "D": "Erythema nodosum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "office", "routine visit", "well", "only complaint", "recent appearance", "brown greasy appearing lesions", "forehead", "peel", "most likely diagnosis"]}
{"question": "A 72-year-old man presents to his primary care physician with a 6-month history of shortness of breath. He says that he used to enjoy playing golf with his friends but now he cannot walk for long enough to play. The shortness of breath is now starting to complicate his ability to get around in daily life. His past medical history is significant for diabetes, hypertension, and early stage prostate cancer that was removed 10 years ago without recurrence. He has smoked 1 pack per day for the past 55 years and drinks about 6 drinks per week. On presentation he is found to be breathing with pursed lips. Physical exam reveals decreased breath sounds on auscultation, increased chest diameter, and hyperresonance to percussion. Which of the following findings would most likely be seen in this patient?", "answer": "Increased residual volume and decreased 1 second forced expiratory volume", "options": {"A": "Decreased residual volume and decreased 1 second forced expiratory volume", "B": "Decreased residual volume and increased 1 second forced expiratory volume", "C": "Increased residual volume and decreased 1 second forced expiratory volume", "D": "Normal residual volume and decreased 1 second forced expiratory volume"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["72 year old man presents", "primary care physician", "month history of shortness", "breath", "used", "playing golf", "friends", "now", "walk", "long", "to play", "shortness of breath", "now starting to complicate", "ability to get", "daily life", "past medical history", "significant", "diabetes", "hypertension", "early cancer", "removed 10 years", "recurrence", "smoked 1 pack", "day", "past 55 years", "drinks", "week", "presentation", "found to", "breathing", "pursed lips", "Physical exam reveals decreased", "auscultation", "increased chest diameter", "hyperresonance", "percussion", "following findings", "most likely", "seen", "patient"]}
{"question": "A 67-year-old male comes into the ED complaining of dyspnea and a heavy feeling in his chest. He reports that over the past month he has become more easily “winded\" to the point that he now sleeps in his living room because he can’t make it up the stairs. A review of systems is notable for headaches and fatigue. On physical exam you note decreased breath sounds and a dullness to percussion on the right. A chest radiograph is obtained, which shows a right-sided pleural effusion. Thoracocentesis is performed and the fluid is analyzed, with results shown below:\n\nVolume: 30 cc of fluid\nPleural fluid protein: 5.8 g/dL\nSerum protein ratio: 7.0 g/dL\nLactate dehydrogenase (LDH): 258 U/L\n\nWhich of the following conditions may have led to the findings in this patient’s pleural cavity?", "answer": "Lymphoma", "options": {"A": "Congestive heart failure", "B": "Liver cirrhosis", "C": "Lymphoma", "D": "Nephrotic syndrome"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["67 year old male", "ED", "dyspnea", "heavy feeling", "chest", "reports", "past month", "more easily winded", "point", "now sleeps", "living room", "cant make", "stairs", "review of systems", "notable", "headaches", "fatigue", "physical exam", "note decreased breath sounds", "dullness", "percussion", "right", "chest radiograph", "obtained", "shows", "right-sided pleural effusion", "Thoracocentesis", "performed", "fluid", "analyzed", "results shown", "Volume", "30 cc", "fluid", "protein", "5.8 g/dL Serum protein ratio", "0 g/dL Lactate dehydrogenase", "U/L", "following conditions", "led", "findings", "patients pleural cavity"]}
{"question": "A 29-year-old G4P0 woman presents following a spontaneous pregnancy loss in the 18th week of her pregnancy. This is her fourth loss in the second trimester and she is concerned about her inability to have a successful pregnancy. She is otherwise healthy and has no acute complaints. Her vitals are unremarkable and exam is notable only for a firm, asymmetric uterus. Laboratory studies are ordered as seen below.\n\nHemoglobin: 9.0 g/dL\nHematocrit: 30%\nLeukocyte count: 6,800/mm^3 with normal differential\nPlatelet count: 199,000/mm^3\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\n\nWhich of the following tests is most likely to elucidate the cause of this patient's pregnancy losses?", "answer": "Hysterosalpingogram", "options": {"A": "Karotyping", "B": "Hysterosalpingogram", "C": "Prolactin level", "D": "TSH level"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old", "woman presents following", "spontaneous pregnancy", "week", "fourth loss", "second trimester", "concerned", "to", "successful pregnancy", "healthy", "acute complaints", "unremarkable", "exam", "notable only", "firm", "asymmetric uterus", "Laboratory studies", "ordered", "seen", "Hemoglobin", "0 g/dL Hematocrit", "30", "Leukocyte count", "6 800 mm 3", "normal differential Platelet count", "mm", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL", "following tests", "most likely to", "cause", "patient's pregnancy losses"]}
{"question": "A 22-year-old woman presents to her primary care physician in April for seasonal allergies. She has suffered from seasonal allergies for the past 2 years and takes diphenhydramine as needed when her symptoms worsen. She has not yet seen a physician for her allergies. She reports that diphenhydramine has been helpful in controlling her symptoms, but she does not like feeling drowsy from the medication. Her past medical history is also notable for well-controlled asthma. She uses an albuterol inhaler on an as-needed basis. She smokes marijuana daily. Her temperature is 99.2°F (37.3°C), blood pressure is 120/70 mmHg, pulse is 76/min, and respirations are 16/min. She has a prominent nasal crease. Her nasal turbinates are boggy and bluish-gray. She has copious thin and watery nasal mucus. The physician suggests replacing diphenhydramine with fexofenadine to improve her drowsiness. What characteristic of fexodenadine allows it to be less sedating than diphenhydramine?", "answer": "Relative lipophobicity", "options": {"A": "Alpha-adrenergic antagonism", "B": "Beta-adrenergic antagonism", "C": "Relative lipophobicity", "D": "Serotonergic antagonism"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "primary care physician", "April", "seasonal allergies", "suffered", "seasonal allergies", "past", "years", "takes diphenhydramine as needed", "symptoms worsen", "not", "seen", "physician", "allergies", "reports", "diphenhydramine", "helpful", "controlling", "symptoms", "not", "feeling drowsy", "medication", "past medical history", "notable", "well-controlled asthma", "uses", "albuterol inhaler", "needed basis", "smokes marijuana daily", "temperature", "99", "3C", "blood pressure", "70 mmHg", "pulse", "76 min", "respirations", "min", "prominent nasal", "nasal turbinates", "boggy", "gray", "copious thin", "watery nasal mucus", "physician suggests replacing diphenhydramine", "fexofenadine to", "drowsiness", "characteristic", "allows", "to", "less sedating than diphenhydramine"]}
{"question": "A 55-year-old male visited his primary care physician complaining of chest pain and progressive shortness of breath worsened by exertion. His vital signs were within normal limits. He reports that he worked in a naval shipyard for 10 years during his twenties. A CT scan of his chest shows diffuse thickening of the pleura and a diagnosis of mesothelioma is made. Assuming this diagnosis is correct, which of the following is most likely to also be present in this patient?", "answer": "Pleural effusion", "options": {"A": "Pneumothorax", "B": "Pleural effusion", "C": "Systemic inflammatory response syndrome", "D": "Bronchioalveolar carcinoma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["55 year old male visited", "primary care physician", "of chest pain", "progressive shortness of breath worsened", "exertion", "vital signs", "normal limits", "reports", "worked", "10 years", "twenties", "CT scan of", "chest shows diffuse thickening of", "pleura", "diagnosis", "mesothelioma", "made", "diagnosis", "correct", "following", "most likely", "present", "patient"]}
{"question": "A 56-year-old man recently diagnosed with cirrhosis secondary to alcohol use presents to the clinic for a follow up evaluation. He states that he has abstained from alcohol and attends a support group regularly. He has not taken any new medications or encountered any sick contacts. The patient's blood pressure is 110/70 mmHg, pulse is 65/min, and respirations are 15/min. His physical exam is grossly unremarkable. He has brought an gastroduodenoscopy report for review, which reveals that the patient has small esophageal varices with red spots. What is the next best step to prevent bleeding?", "answer": "Nadolol", "options": {"A": "Endoscopic sclerotherapy", "B": "Metoprolol", "C": "Nadolol", "D": "Repeat endoscopy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man recently diagnosed", "cirrhosis secondary to alcohol use presents", "clinic", "follow up evaluation", "states", "alcohol", "attends", "support group", "not taken", "new medications", "encountered", "sick contacts", "patient's blood pressure", "70 mmHg", "pulse", "65 min", "respirations", "min", "physical exam", "unremarkable", "brought", "gastroduodenoscopy report", "review", "reveals", "patient", "small esophageal varices", "red spots", "next best step to prevent bleeding"]}
{"question": "A 70-year-old man is brought to the emergency department by his wife for incomprehensible speech. Upon first inspection you note the man is drooling and his eyes are tearing excessively. The patient's wife explains that the man was tilling the fields on the family beet farm when she found him collapsed on a pile of freshly picked beets. The patient seemed confused so the wife brought him in promptly, and states it has only been ten minutes since the patient was found down in the fields. Physical exam is deferred due to a confused and combative patient who is speaking clearly yet his sentences do not make any sense. The patients clothes are removed in the ED. Vital signs are currently being obtained. Which of the following is the best initial step in management?", "answer": "2-pralidoxime", "options": {"A": "Neostigmine", "B": "Physostigmine", "C": "2-pralidoxime", "D": "Intubation"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["70 year old man", "brought", "emergency department", "wife", "incomprehensible speech", "first inspection", "note", "man", "drooling", "eyes", "tearing excessively", "patient's wife", "man", "fields", "family beet farm", "found", "collapsed", "pile", "picked beets", "patient", "confused", "wife brought", "states", "only", "ten minutes", "patient", "found", "fields", "Physical exam", "deferred due to", "confused", "combative patient", "speaking", "sentences", "not make", "sense", "patients clothes", "removed", "ED", "Vital signs", "currently", "obtained", "following", "best initial step", "management"]}
{"question": "A 75-year-old man presents to the physician for his annual blood pressure visit and blood work. He has no complaints other than occasional knee pain. The past medical history includes hypertension. He has had knee osteoarthritis for several years and takes occasional acetaminophen for pain control. His diet is full of vegetables. He exercises every day. He has no history of smoking. He had a brother who died at the age of 84 due to hematologic malignancy. The temperature is 36.8℃ (98.2℉), and the blood pressure is 125/85 mm Hg. The physical examination shows no abnormalities other than a reduced range of motion and crepitus in both knees. The laboratory test results are as follows:\nHemoglobin 15 g/dL\nLeukocyte count 58,000/mm3\nPlatelet count 250,000/mm3\nFlow cytometry on the peripheral blood reveals an absolute lymphocyte count of 50,000/mm3. Which of the following is the most likely diagnosis?", "answer": "Chronic lymphocytic leukemia (CLL)", "options": {"A": "Chronic lymphocytic leukemia (CLL)", "B": "Monoclonal B cell lymphocytosis (MBL)", "C": "Monoclonal gammopathy of undetermined significance (MGUS)", "D": "Multiple myeloma (MM)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["75 year old man presents", "physician", "annual blood pressure visit", "blood work", "complaints other", "occasional knee pain", "past medical history includes hypertension", "knee osteoarthritis", "years", "takes occasional acetaminophen", "pain control", "diet", "full", "vegetables", "exercises", "day", "history of smoking", "brother", "died", "age", "84", "hematologic malignancy", "temperature", "36", "98", "blood pressure", "85 mm Hg", "physical examination shows", "abnormalities", "reduced range of motion", "crepitus", "knees", "laboratory test results", "follows", "Hemoglobin", "g Leukocyte count 58", "mm3 Platelet count", "Flow cytometry", "peripheral blood reveals", "absolute lymphocyte count", "50", "mm3", "following", "most likely diagnosis"]}
{"question": "A 60-year-old man comes to the physician because of a 2-month history of cough productive of yellow sputum with occasional streaks of blood. He has a history of pulmonary tuberculosis. He is afebrile. Pulmonary examination shows inspiratory crackles at the left infraclavicular area. An x-ray of his chest shows a radiopaque mass in the left upper lung lobe that shifts upon repositioning. A sputum sample does not grow acid-fast bacteria despite multiple cultures. Which of the following is the most likely cause of this patient's condition?", "answer": "Opportunistic colonization", "options": {"A": "Asbestos inhalation", "B": "Neoplastic transformation", "C": "Opportunistic colonization", "D": "Abscess formation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["60 year old man", "physician", "2 month history", "cough productive", "yellow", "occasional streaks", "blood", "history of pulmonary tuberculosis", "afebrile", "Pulmonary examination shows inspiratory crackles", "left infraclavicular area", "x-ray of", "chest shows", "radiopaque mass", "left upper lung lobe", "shifts", "repositioning", "sputum sample", "not", "acid-fast bacteria", "multiple cultures", "following", "most likely cause", "patient's condition"]}
{"question": "An 11-month-old boy is brought to the emergency department by his mother after she observed jerking movements of his arms and legs for about 30 seconds earlier that morning. He has not had fever, cough, or a runny nose. He has been healthy, except for occasional eczema. He was delivered at home in Romania. His mother had no prenatal care. She reports that he has required more time to reach developmental milestones compared to his older brother. The patient's immunization records are not available. He takes no medications. He appears pale with blue eyes and has a musty odor. He has poor eye contact. Which of the following would have most likely prevented the patient's symptoms?", "answer": "Dietary restriction of phenylalanine", "options": {"A": "Levothyroxine therapy during pregnancy", "B": "Dietary restriction of phenylalanine", "C": "Daily allopurinol intake", "D": "Avoidance of fasting states"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "emergency department", "mother", "observed jerking movements", "arms", "legs", "30 seconds earlier", "morning", "not", "fever", "cough", "runny nose", "healthy", "occasional eczema", "delivered at home", "Romania", "mother", "prenatal care", "reports", "required more time to reach developmental milestones compared", "older brother", "patient's immunization", "not available", "takes", "medications", "appears pale", "blue eyes", "musty odor", "poor eye contact", "following", "most likely prevented", "patient's symptoms"]}
{"question": "A researcher hypothesizes that low birth weight is related to obesity later in life. He conducts a study with a 95% confidence interval with a p-value of 0.049 to disprove his null hypothesis. He rejects his null hypothesis and concludes that low birth weight is associated with obesity. Which of the following statements best associates with his study?", "answer": "A type 2 error is not possible in this case.", "options": {"A": "Confidence interval should have been 90%.", "B": "A type 2 error is not possible in this case.", "C": "A type 2 error has been made.", "D": "A type 1 error has been made."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["researcher", "low birth weight", "related", "obesity later", "life", "conducts", "study", "95", "confidence interval", "p-value", "0", "to", "null hypothesis", "rejects", "null hypothesis", "concludes", "low birth weight", "associated with obesity", "following statements best associates", "study"]}
{"question": "A 52-year-old woman presents to her primary care physician for abdominal pain and diarrhea. The patient states that she has been experiencing watery diarrhea for weeks now. During this same period she states she has been constantly thirsty and does not have the same energy levels that she once had. The patient has a past medical history of anxiety and depression and is currently taking fluoxetine. She was recently treated for a middle ear infection and sinusitis with amoxicillin-clavulanic acid one week ago. Her temperature is 99.5°F (37.5°C), blood pressure is 110/58 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 2.9 mEq/L\nHCO3-: 27 mEq/L\nBUN: 25 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.4 mg/dL\nCa2+: 10.2 mg/dL\nAST: 12 U/L\nALT: 10 U/L\n\nWhich of the following is associated with the most likely diagnosis?", "answer": "Impaired iron absorption", "options": {"A": "Enterotoxin", "B": "Impaired iron absorption", "C": "Increased serotonin production", "D": "Invasive bacterial infection"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "abdominal pain", "diarrhea", "patient states", "experiencing watery diarrhea", "weeks now", "same period", "states", "constantly thirsty", "not", "same energy levels", "patient", "past medical anxiety", "depression", "currently taking fluoxetine", "recently treated", "middle ear infection", "sinusitis with amoxicillin-clavulanic acid one week", "temperature", "99", "blood pressure", "58 mmHg", "pulse", "100 min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory values", "obtained", "shown", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "2.9 mEq/L HCO3", "27 mEq/L", "mg/dL Glucose", "99 mg/dL Creatinine", "1.4 mg/dL Ca2", "10", "mg/dL AST", "U/L ALT", "10 U/L", "following", "associated with", "likely diagnosis"]}
{"question": "A 3-week-old newborn is brought to the physician by his parents because of poor feeding, irritability, and frequent vomiting over the past week. The vomitus is greenish in color and smells strange. His parents have tried to feed him every 4 hours, but the patient often spits up or refuses to eat. The patient was born at term and had his first bowel movement at 50 hours of life. He has since had one bowel movement daily. He is at the 50th percentile for length, 10th percentile for weight, and 40th percentile for head circumference. He does not appear to be in acute distress. His temperature is 36.9°C (98.4°F), pulse is 140/min, respirations are 40/min, and blood pressure is 90/60 mm Hg. Physical examination shows that the patient has small, low-set ears, a broad and flat nasal bridge, and a large space between the first and second toes bilaterally. The abdomen is distended. When the finger is removed following a rectal exam, there is an explosive release of stool from the patient's rectum. An x-ray of the abdomen shows a section of dilated colon followed by a segment of colon without stool or air. Which of the following is most likely to confirm the diagnosis?", "answer": "Rectal suction biopsy", "options": {"A": "CT scan of the abdomen", "B": "Transabdominal ultrasonography", "C": "Anorectal manometry", "D": "Rectal suction biopsy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["3 week old newborn", "brought", "physician", "parents", "poor feeding", "irritability", "frequent vomiting", "past week", "vomitus", "color", "smells", "parents", "to feed", "4 hours", "patient often spits", "refuses to eat", "patient", "born", "term", "first bowel", "50 hours", "life", "since", "one bowel movement daily", "50th percentile", "length", "percentile", "weight", "percentile", "head circumference", "not appear to", "acute distress", "temperature", "36", "98 4F", "pulse", "min", "respirations", "40 min", "blood pressure", "90 60 mm Hg", "Physical examination shows", "patient", "small", "low-set ears", "broad", "flat nasal bridge", "large space", "first", "second toes", "abdomen", "distended", "finger", "removed following", "rectal exam", "explosive release", "stool", "patient's rectum", "x-ray of", "abdomen shows", "section", "dilated colon followed by", "segment of colon", "stool", "air", "following", "most likely to confirm", "diagnosis"]}
{"question": "A 13-year-old boy is brought to the physician because of progressive left leg pain for 2 months, which has started to interfere with his sleep. His mother has been giving him ibuprofen at night for “growing pains,” but his symptoms have not improved. One week before the pain started, the patient was hit in the thigh by a baseball, which caused his leg to become red and swollen for several days. Vital signs are within normal limits. Examination shows marked tenderness along the left mid-femur. His gait is normal. Laboratory studies show a leukocyte count of 21,000/mm3 and an ESR of 68 mm/h. An x-ray of the left lower extremity shows multiple lytic lesions in the middle third of the femur, and the surrounding cortex is covered by several layers of new bone. A biopsy of the left femur shows small round blue cells. Which of the following is the most likely diagnosis?", "answer": "Ewing sarcoma", "options": {"A": "Osteosarcoma", "B": "Osteochondroma", "C": "Ewing sarcoma", "D": "Osteoid osteoma"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "of progressive left leg pain", "months", "started to interfere", "sleep", "mother", "giving", "ibuprofen", "night", "growing pains", "symptoms", "not improved", "One week", "pain started", "patient", "hit", "thigh", "baseball", "caused", "leg to", "red", "swollen", "days", "Vital signs", "normal limits", "Examination shows marked tenderness", "left", "femur", "gait", "normal", "Laboratory show", "leukocyte count", "mm3", "ESR", "68 mm/h", "x-ray of", "left lower extremity shows multiple lytic", "middle third", "femur", "surrounding cortex", "covered", "layers", "new bone", "biopsy of", "left femur shows small round blue cells", "following", "most likely diagnosis"]}
{"question": "A 55-year-old male with a history of stage I colon cancer status-post left hemicolectomy presents to your office for follow-up. You intend to discuss the results from his recent surveillance colonoscopy, which showed no remaining cancer, no polyps, and a well-healed anastmosis. During your meeting, you note that the patient is exhibiting the defense mechanism of suppression. Which of the following statements from the patient is consistent with your impression?", "answer": "\"I really haven't thought about the colonoscopy until today. Worrying before getting the results wasn't going to help anything.\"", "options": {"A": "\"Last week I volunteered for the local Cancer Society. Helping other cancer patients just makes me feel better.\"", "B": "\"Oh, doctor, I'm just so grateful to be seeing you. I just know you've cured my cancer. I probably don't even need to check anymore.\"", "C": "\"I'm sorry I was late today. I also didn't get any of the labs you asked for.\"", "D": "\"I really haven't thought about the colonoscopy until today. Worrying before getting the results wasn't going to help anything.\""}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["male", "history of stage I colon cancer", "left hemicolectomy presents", "office", "follow-up", "to discuss", "results", "recent surveillance colonoscopy", "showed", "remaining cancer", "polyps", "well healed", "meeting", "note", "patient", "exhibiting", "defense mechanism", "suppression", "following statements", "patient", "consistent with", "impression"]}
{"question": "A 67-year-old man is brought to the emergency department with severe, crushing, retrosternal chest pain for the last 45 minutes. The pain radiates to his left shoulder and is associated with sweating. The past medical history is significant for hypercholesterolemia, for which he takes lovastatin. He smoked as a youth but quit at 40 years of age. On arrival at the emergency department, the vital signs were as follows: pulse 58/min, respiratory rate 22/min, and blood pressure 90/56 mm Hg. He is sweating profusely. The jugular venous pulse is visible 2.5 cm above the sternal angle. Auscultation reveals soft S1 and S2 heart sounds with an added S4 and bilateral inspiratory crackles at the lung bases. The electrocardiogram shows ST-elevations in leads V1 and V2. A diagnosis of an anteroseptal infarction is made. The patient was given aspirin on the way to the hospital. He is started on dopamine, morphine, nitroglycerin, and streptokinase. Which of the following would be the most concerning development over the next 24h this patient?", "answer": "Hemoptysis", "options": {"A": "Hemoptysis", "B": "Easy fatigability", "C": "Persistent ST-segment elevation", "D": "Shortness of breath"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old man", "brought", "emergency department", "severe", "crushing", "retrosternal chest pain", "45 minutes", "pain radiates", "left shoulder", "associated with sweating", "past medical history", "significant", "hypercholesterolemia", "takes lovastatin", "smoked", "youth", "quit", "40", "age", "arrival", "emergency department", "vital signs", "follows", "pulse 58 min", "respiratory rate", "min", "blood pressure 90", "mm Hg", "sweating", "jugular venous pulse", "visible", "sternal angle", "Auscultation reveals soft S1", "S2 heart sounds", "added S4", "bilateral inspiratory crackles", "lung bases", "electrocardiogram shows ST-elevations", "leads V1", "V2", "diagnosis", "infarction", "made", "patient", "given aspirin", "hospital", "started", "dopamine", "morphine", "nitroglycerin", "streptokinase", "following", "most concerning development", "next 24h", "patient"]}
{"question": "A 65-year-old male presents to his pulmonologist for a follow-up visit. He has a history of chronic progressive dyspnea over the past five years. He uses oxygen at home and was seen in the emergency room two months prior for an exacerbation of his dyspnea. He was discharged following stabilization. His past medical history is notable for hyperlipidemia and hypertension. He drinks alcohol socially and has a 45 pack-year smoking history. His temperature is 98.6°F (37°C), blood pressure is 140/75 mmHg, pulse is 110/min, and respirations are 22/min. On examination, increased work of breathing is noted. The physician decides to start the patient on an additional medication that has both mucoactive and anti-oxidative properties. What is the primary mechanism of action of this medication in the lungs?", "answer": "Disulfide bond cleavage", "options": {"A": "DNA hydrolysis", "B": "Disulfide bond cleavage", "C": "Endothelin-1 antagonism", "D": "Reduction in airway surface tension"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old male presents", "pulmonologist", "follow-up visit", "history", "chronic progressive", "past five years", "uses oxygen at home", "seen", "emergency room two months prior", "exacerbation", "dyspnea", "discharged following stabilization", "past medical history", "notable", "hyperlipidemia", "hypertension", "drinks alcohol", "pack-year smoking history", "temperature", "98", "blood pressure", "75 mmHg", "pulse", "min", "respirations", "min", "examination", "increased work of breathing", "noted", "physician", "to start", "patient", "additional medication", "oxidative properties", "primary mechanism of action", "medication", "lungs"]}
{"question": "A 36-year-old woman, gravida 3, para 2, at 42 weeks' gestation comes to the physician for induction of labor. Her pregnancy has been uncomplicated. Her two other children were born after uncomplicated vaginal deliveries at 41 and 42 weeks' gestation, respectively. Her only medication is a prenatal vitamin. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (200 lb); BMI is 33 kg/m2. Her temperature is 36.8°C (98.4°F), pulse is 90/min, respirations are 14/min, and blood pressure is 110/80 mmHg. Examination shows a nontender, soft uterus consistent in size with a 42-weeks' gestation. This patient's child is at greatest risk for which of the following complications?", "answer": "Meconium aspiration", "options": {"A": "Polyhydramnios", "B": "Acute respiratory distress syndrome", "C": "Meconium aspiration", "D": "Placental abruption"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old woman", "gravida 3", "para 2", "weeks", "gestation", "physician", "induction of labor", "pregnancy", "uncomplicated", "two", "children", "born", "uncomplicated vaginal deliveries", "weeks", "gestation", "only medication", "prenatal vitamin", "5 ft 5", "tall", "kg", "200", "BMI", "kg/m2", "temperature", "36", "98 4F", "pulse", "90 min", "respirations", "min", "blood pressure", "80 mmHg", "Examination shows", "nontender", "soft uterus consistent", "size", "weeks", "gestation", "patient's child", "greatest risk", "following complications"]}
{"question": "The only immunoglobulin found as a dimer has what primary function?", "answer": "Inhibiting bacterial adherance and colonization of mucous membranes", "options": {"A": "Protect against invasive helminth infection", "B": "Protect against viral infections", "C": "Inhibiting bacterial adherance and colonization of mucous membranes", "D": "Provides the most specific recognition to circulating antigens in the bloodstream"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["only immunoglobulin found", "dimer", "primary function"]}
{"question": "A 47-year-old woman is brought to the emergency department by paramedics. She was found unconscious on a park bench by a bystander. Her history is unobtainable. Vitals include a pulse of 64/min, a respiratory rate of 7/min, and a blood pressure of 110/70 mm Hg. On examination, the patient is unresponsive to voice and touch but shows a flexor response to pain. Her breathing is shallow. The pupils are constricted, and a response to light cannot be determined. An arterial blood gas sample reveals:\npH 7.26\nPco2 70 mm Hg\nHCO3-  26 mEq/L\nWhich of the following could explain this patient's presentation?", "answer": "Opioid overdose", "options": {"A": "Diabetic ketoacidosis", "B": "Diuretic overdose", "C": "Hyperventilation", "D": "Opioid overdose"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department", "paramedics", "found unconscious", "park", "bystander", "history", "include", "pulse", "64 min", "respiratory rate", "min", "blood pressure", "70 mm Hg", "examination", "patient", "unresponsive to voice", "touch", "shows", "flexor response to pain", "breathing", "shallow", "pupils", "constricted", "response to light", "arterial blood sample reveals", "pH 7", "Pco2 70 mm Hg HCO3", "mEq/L", "following", "patient's presentation"]}
{"question": "A 72-year-old woman with a 40 pack-year history of smoking presents to your office with jaundice. After a thorough workup, you determine that the patient has pancreatic cancer. Which of the following is the most appropriate initial statement to inform the patient of her condition?", "answer": "\"I have bad news I need to share with you. Please sit down so we can discuss.\"", "options": {"A": "\"Have you ever heard of pancreatic cancer?\"", "B": "\"I have bad news I need to share with you. Please sit down so we can discuss.\"", "C": "\"Have you designated a healthcare proxy?\"", "D": "\"Your test results are consistent with a pancreatic adenocarcinoma.\""}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["72 year old woman", "40 pack", "history of smoking presents", "office", "jaundice", "workup", "patient", "pancreatic cancer", "following", "most appropriate initial statement to inform", "patient", "condition"]}
{"question": "A 40-year-old man is referred to an optometrist. He complains of mild vision impairment over the last 6 months. His vision has continued to slowly deteriorate and his condition is now affecting his night driving. Past medical history is significant for well-controlled schizophrenia. He takes a low-potency typical antipsychotics and a multivitamin every day. He has been compliant with his medication and has regular follow-up visits. What is the best first step in the management of this patient’s symptoms?", "answer": "Slit-lamp examination", "options": {"A": "Decrease medication dosage", "B": "Reassurance", "C": "Ocular examination under anesthesia", "D": "Slit-lamp examination"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["40 year old man", "referred", "optometrist", "mild vision impairment", "last", "months", "vision", "continued to slowly deteriorate", "condition", "now affecting", "night driving", "Past medical history", "significant", "well-controlled schizophrenia", "takes", "low potency typical antipsychotics", "multivitamin", "day", "compliant", "medication", "regular follow-up visits", "best first step", "management", "patients"]}
{"question": "A 65-year-old man presents with a 6-month history of repeated falls, postural dizziness, progressive fatigue, generalized weakness and a 13.6 kg (30 lb) weight loss. He is a vegetarian. The patient’s family says that he had been high functioning but has had significant behavioral changes over the past year. The patient denies any smoking history, alcohol consumption, or illicit drug use. No significant family history. His vital signs include: blood pressure 90/50 mm Hg without postural changes, pulse 92/min, respiratory rate 16/min, temperature 37.0℃ (98.6℉). Physical examination reveals a poorly groomed, disheveled, thin man. He is irritable, paranoid, and delusional but denies any hallucinations. An unstable, wide-based ataxic gait is noted. Laboratory results are significant for the following:\nHb 6.1 g/dL\nMCV 109 fL\nPlatelets 90,0000/mm3\nTotal count 3,000/mm3\nReticulocyte count 0.8%\nA peripheral blood smear demonstrates hypersegmented neutrophils. Anti-intrinsic factor antibodies are negative. Which of the following is the most likely cause of this patient’s condition?\n ", "answer": "Vitamin B12 deficiency", "options": {"A": "Hypothyroidism", "B": "Folate deficiency", "C": "Vitamin B12 deficiency", "D": "Parvovirus infection"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["65 year old man presents", "month history of repeated falls", "postural dizziness", "progressive fatigue", "generalized weakness", "13.6 kg", "30", "weight loss", "vegetarian", "patients family", "high functioning", "significant behavioral changes", "past year", "patient denies", "smoking history", "alcohol consumption", "illicit drug use", "significant family history", "vital signs include", "blood pressure 90 50 mm Hg", "postural changes", "pulse", "min", "respiratory rate", "min", "temperature", "0", "98", "Physical examination reveals", "poorly groomed", "thin man", "irritable", "delusional", "denies", "hallucinations", "unstable", "wide-based ataxic gait", "noted", "Laboratory results", "significant", "following", "Hb", "g MCV", "fL Platelets 90", "mm3 Total count", "Reticulocyte", "0.8", "peripheral blood smear demonstrates hypersegmented neutrophils", "Anti-intrinsic factor antibodies", "negative", "following", "most likely cause", "patients condition"]}
{"question": "A 42-year-old man presents to establish care with a family physician after having progressively worsening back pain. He has recently migrated from Sweden and has not had any checkups in the last 3 years. He first started having back pain 3 years ago, but his pain has begun to be excruciating in the mornings. He is no longer able to get relief with over the counter medications. He also feels stiff every morning and this usually lasts between 30 minutes and an hour. Both of his knees are also very painful, particularly upon standing up from a seated position. His pain improves when he moves around, so he tries to be somewhat physically active. He also reports that he cannot use his hands for long periods of time due to joint pain and stiffness. His father and sister also have joint issues, and his mother was recently diagnosed with osteoporosis. He has been a smoker for 13 years. Upon physical examination, his wrist and proximal interphalangeal (PIP) joints are warm and swollen. Which of the following is the next best step in management?", "answer": "Testing for serum ESR and autoantibodies", "options": {"A": "Testing for serum Ca and PTH", "B": "Calcium and Vitamin D prescription", "C": "Testing for serum ESR and autoantibodies", "D": "Testing for serum ferritin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man presents to establish care", "family physician", "worsening back pain", "recently migrated", "Sweden", "not", "checkups", "years", "first started", "back pain", "years", "pain", "begun to", "excruciating", "mornings", "longer able to", "relief", "over the counter medications", "feels stiff", "morning", "usually", "30 minutes", "hour", "knees", "very painful", "standing up", "seated position", "pain improves", "moves", "to", "somewhat physically active", "reports", "use", "hands", "long periods", "time", "joint pain", "stiffness", "father", "sister", "joint issues", "mother", "recently diagnosed", "osteoporosis", "smoker", "years", "physical examination", "wrist", "proximal interphalangeal", "joints", "warm", "swollen", "following", "next best step", "management"]}
{"question": "A previously healthy 28-year-old man comes to the emergency department because of dizziness and palpitations for 2 days. Prior to the onset of the symptoms, he attended a bachelor party where he lost several drinking games. An ECG is shown. Which of the following is the most likely diagnosis?", "answer": "Paroxysmal atrial fibrillation", "options": {"A": "Paroxysmal atrial fibrillation", "B": "Brugada syndrome", "C": "Ventricular tachycardia", "D": "Sick sinus syndrome"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["healthy", "year old man", "emergency department", "dizziness", "palpitations", "2 days", "Prior to", "onset", "symptoms", "attended", "bachelor party", "lost several drinking games", "ECG", "shown", "following", "most likely diagnosis"]}
{"question": "A 45-year-old woman comes to the physician because of fatigue, abdominal cramps, watery diarrhea, and a weight loss of 4 kg (8.8 lb) over the last 4 months. She has recently avoided drinking alcohol and eating spicy food because it worsens her diarrhea and causes episodes of heart palpitations and reddening of the face and neck. She takes lisinopril for hypertension. Her temperature is 36.5°C (97.7°F), pulse is 98/min, and blood pressure is 149/90 mm Hg. The abdomen is soft, and there is mild tenderness to palpation with no guarding or rebound. Laboratory studies show an increased urine 5-hydroxyindoleacetic acid concentration. Further evaluation of this patient will most likely show which of the following?", "answer": "Pulmonic valve stenosis", "options": {"A": "Achlorhydria", "B": "Adrenal medullary mass", "C": "Multiple peptic ulcers", "D": "Pulmonic valve stenosis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "fatigue", "abdominal cramps", "watery diarrhea", "weight loss of", "kg", "8.8", "last", "months", "recently", "drinking alcohol", "eating spicy food", "worsens", "diarrhea", "causes episodes of heart palpitations", "face", "neck", "takes lisinopril", "hypertension", "temperature", "36", "97", "pulse", "98 min", "blood pressure", "90 mm Hg", "abdomen", "soft", "mild tenderness", "palpation", "guarding", "Laboratory studies show", "increased urine", "hydroxyindoleacetic acid concentration", "Further evaluation", "patient", "most likely show", "following"]}
{"question": "A 66-year-old man presents to the emergency department due to a productive cough. His cough has been increasing in frequency and severity over the course of 3 days, and his sputum production has increased in volume. The color of his sputum is yellow-green. He denies any chest pain or palpitations but has experienced worsening shortness of breath with exertion and at rest, which is above his baseline. He has not noticed any changes in his weight or edema in his lower extremities. He denies any recent history of long travel. Medical history is significant for hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD). He has been hospitalized four times for similar symptoms within the last year. He has smoked approximately 1 pack of cigarettes per day for the past 45 years. His temperature is 102°F (38.9°C), blood pressure is 156/94 mmHg, pulse is 101/min, and respirations are 26/min with an oxygen saturation of 85% on room air. On physical exam, the patient has difficulty speaking, and there is asynchronous motion between the chest and abdomen with respiration. Wheezing is appreciated on pulmonary auscultation. An ECG demonstrates normal sinus rhythm. A chest radiograph is obtained, and he is administered supplemental oxygen. He is started on ipratropium, albuterol, and methylprednisolone. Which of the following should be added to this patient's treatment regimen?", "answer": "Levofloxacin", "options": {"A": "Cefazolin", "B": "Ceftriaxone", "C": "Levofloxacin", "D": "Penicillin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["66 year old man presents", "emergency department", "productive cough", "cough", "increasing", "frequency", "severity", "course", "3 days", "sputum production", "increased", "volume", "color of", "sputum", "yellow-green", "denies", "chest pain", "palpitations", "experienced worsening shortness of breath", "exertion", "rest", "baseline", "not", "changes in", "weight", "edema", "lower extremities", "denies", "recent history long travel", "Medical", "significant", "hypertension", "hyperlipidemia", "chronic obstructive pulmonary disease", "hospitalized four times", "similar symptoms", "last year", "smoked approximately", "pack", "cigarettes", "day", "past", "years", "temperature", "blood pressure", "mmHg", "pulse", "min", "respirations", "26 min", "oxygen saturation", "85", "room air", "physical exam", "patient", "difficulty speaking", "asynchronous motion", "chest", "abdomen", "respiration", "Wheezing", "pulmonary auscultation", "ECG demonstrates normal sinus rhythm", "chest radiograph", "obtained", "administered supplemental oxygen", "started", "ipratropium", "albuterol", "methylprednisolone", "following", "added", "patient's"]}
{"question": "A 55-year-old man presents with bloody nasal secretions and shortness of breath. He reports he has lost 4 kg (8.8 lb) in the last two months with no changes in his diet. He has also been suffering from mild to moderate joint pain in the left knee for the last year. His past medical history is unremarkable. His vitals include: blood pressure 120/70 mm Hg, temperature 37.0℃ (98.6℉), pulse 70/min, respiratory rate 14/min. Physical examination is significant for nasal ulcers. Diffuse crackles are present over all lobes of the lung bilaterally. Laboratory findings are significant for the following:\nHemoglobin 12.9 g/dL\nHematocrit 37.7%\nLeukocyte count 5500/mm3\nNeutrophils 65%\nLymphocytes 30%\nMonocytes 5%\nMean corpuscular volume 82.2 μm3\nPlatelet count 190,000/mm3\nErythrocyte sedimentation rate 35 mm/h\nC-reactive protein 14 mg/dL\nCreatinine 3.09 mg/dL\nThe patient is prescribed a corticosteroid nasal spray and oral antibiotics but returns in 2 weeks without any clinical improvement. Which of the following would most likely confirm the diagnosis in this patient?", "answer": "Antineutrophil cytoplasmic antibodies", "options": {"A": "Anti-citrullinated protein antibodies", "B": "Erythrocyte sedimentation rate", "C": "Anti-histone bodies", "D": "Antineutrophil cytoplasmic antibodies"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["55 year old man presents", "bloody nasal secretions", "shortness of breath", "reports", "lost 4 kg", "8.8", "last two months", "changes", "diet", "suffering", "mild to moderate joint pain", "left knee", "year", "past medical history", "unremarkable", "include", "blood pressure", "70 mm Hg", "temperature", "0", "98", "pulse 70 min", "respiratory rate", "min", "Physical examination", "significant", "nasal ulcers", "Diffuse crackles", "present", "lobes of", "lung", "Laboratory findings", "significant", "following", "Hemoglobin", "count", "Mean corpuscular volume", "rate", "C", "mg", "mg", "patient", "prescribed", "corticosteroid nasal spray", "oral antibiotics", "returns", "2 weeks", "clinical improvement", "following", "most likely confirm", "diagnosis", "patient"]}
{"question": "A 25-year-old Hispanic male presents with heat intolerance and recent weight loss. Serum analysis shows increased levels of T4 and T3, as well as the presence of thyroglobulin-stimulating immunoglobulins. The patient is found to be tachycardic and has marked edema and waxy discoloration in his legs. Which of the following would be consistent with this patient's disease?", "answer": "Exophthalmos", "options": {"A": "Sympathetic underactivity", "B": "Anti-thyroglobin antibodies", "C": "Exophthalmos", "D": "Increased TSH release"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old Hispanic male presents", "heat intolerance", "recent weight loss", "Serum analysis shows increased levels", "T4", "presence", "thyroglobulin stimulating immunoglobulins", "patient", "found to", "tachycardic", "marked edema", "waxy discoloration", "legs", "following", "consistent with", "patient's disease"]}
{"question": "A 3-day-old male is evaluated in the hospital nursery for delayed passage of meconium. His mother is breastfeeding and has started to produce milk. The patient has been feeding well every two hours and is urinating over eight times per day. The patient was born at 35 weeks gestation to a 27-year-old gravida 4. The patient is of Ashkenazi Jewish descent, and the patient’s parents denied all prenatal genetic testing. The pregnancy was uncomplicated until the patient’s mother had spontaneous rupture of membranes at 35 weeks gestation. The patient’s three older siblings are all healthy. In the hospital nursery, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 48/32 mmHg, pulse is 164/min, and respirations are 48/min. On physical exam, he appears to be in moderate distress. He has no dysmorphic features, and his abdomen is distended and non-tender. Bowel sounds are absent.\n\nWhich of the following is the best next step in management?", "answer": "Abdominal radiograph", "options": {"A": "Abdominal radiograph", "B": "Contrast enema", "C": "Upper gastrointestinal series", "D": "Sweat testing"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["3 day old male", "evaluated", "hospital nursery", "delayed passage of meconium", "mother", "breastfeeding", "started to", "milk", "patient", "feeding well", "two hours", "eight times", "day", "patient", "born", "35 weeks gestation", "27 year old gravida 4", "patient", "Ashkenazi Jewish descent", "patients parents denied", "prenatal genetic", "pregnancy", "uncomplicated", "patients mother", "spontaneous rupture of membranes", "35 weeks gestation", "patients three older siblings", "healthy", "hospital nursery", "patients temperature", "98", "36", "blood pressure", "48", "mmHg", "pulse", "min", "respirations", "48 min", "physical exam", "appears to", "moderate distress", "dysmorphic features", "abdomen", "distended", "non-tender", "Bowel sounds", "absent", "following", "best next step", "management"]}
{"question": "A 78-year-old woman presents to the office for an annual health check-up with her family physician accompanied by her daughter. She has no complaints during this visit but her daughter states that she is having difficulty locating objects such as the television remote, car keys, and her purse. Her medical history is significant for Alzheimer’s dementia, coronary artery disease, diabetes mellitus, hypothyroidism, congestive heart failure, osteoarthritis and centrilobular emphysema. The patient takes memantine, atorvastatin, metformin, levothyroxine, lisinopril, aspirin, albuterol, and ipratropium. The patient’s vitals are within normal limits today. Physical exam reveals an elderly female in no acute distress, oriented to person, place and year, but not to month or day of the week. She has a 3/6 holosystolic murmur at the left sternal border along with an S3 gallop. There are mild crackles at the lung bases. The remainder of the exam is normal. A previous urine culture reports growth of > 100,000 CFU of Enterobacter. Urinalysis findings are offered below:\nLeukocyte esterase  positive\nWBCs 50-100 cell/HPF\nNitrites positive\nRBCs 2 cell/HPF\nEpithelial cells 2 cell/HPF\nUrine pH 5.7\nWhich of the following is the most appropriate next step?", "answer": "No treatment is necessary", "options": {"A": "TMP-SMX", "B": "Nitrofurantoin", "C": "Levofloxacin", "D": "No treatment is necessary"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "office", "annual health", "family physician", "daughter", "complaints", "visit", "daughter states", "difficulty", "objects", "television remote", "car", "medical history", "significant", "Alzheimers dementia", "coronary artery disease", "diabetes mellitus", "hypothyroidism", "congestive heart failure", "osteoarthritis", "centrilobular emphysema", "patient takes memantine", "atorvastatin", "metformin", "levothyroxine", "lisinopril", "aspirin", "albuterol", "ipratropium", "patients", "normal limits today", "Physical exam reveals", "elderly female", "acute distress", "oriented to person", "place", "year", "not", "month", "day of the week", "3/6 holosystolic murmur", "left sternal border", "S3 gallop", "mild crackles", "lung bases", "exam", "normal", "previous urine culture reports growth", "100", "Enterobacter", "Urinalysis findings", "offered", "Leukocyte esterase", "positive", "cell", "Nitrites", "RBCs", "Epithelial cells", "Urine pH", "7", "following", "most appropriate next step"]}
{"question": "A 45-year-old woman comes to the physician because of a 2-week history of painful ulcers in her mouth. Over the past 2 months, she has had increasing fatigue and difficulties concentrating. She has a history of rheumatoid arthritis and was started on a new medication 4 months ago. Examination shows pallor of the mucosal membranes and three tender ulcerative lesions in her mouth. Her hemoglobin concentration is 8.7 g/dL and mean corpuscular volume is 109 μm3. A blood smear shows hypersegmented neutrophils. Which of the following is the most likely cause of this patient's findings?", "answer": "Deficient nitrogenous base production", "options": {"A": "Deficient heme synthesis", "B": "Deficient erythropoietin secretion", "C": "Deficient nitrogenous base production", "D": "Deficient β-globin chains"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "2 history", "painful ulcers", "mouth", "past", "months", "increasing fatigue", "difficulties concentrating", "history of rheumatoid arthritis", "started", "new medication", "months", "Examination shows pallor", "mucosal membranes", "three tender ulcerative lesions", "mouth", "hemoglobin concentration", "g/dL", "mean corpuscular volume", "m3", "blood smear shows hypersegmented neutrophils", "following", "most likely cause", "patient's findings"]}
{"question": "A 25-year-old woman presents to her primary care provider for evaluation of a \"painful mass in my left groin.\" She says that her symptoms began 4 days ago as a painful mass that slowly enlarged, ruptured, and ulcerated. However, she denies fever, chills, dysuria, or hematuria. Three weeks prior to her current symptoms she noted a small, painless ulcer on her labium majorum that resolved after a few days. She admits to having unprotected sex with a male partner a month ago while she was traveling in Southeast Asia. Temperature is 99°F (37.2°C), blood pressure is 139/84 mmHg, pulse is 76/min, and respirations are 18/min. Physical examination is significant for left-sided, tender, ulcerative lymph nodes with a dark discoloration. Which of the following is most likely to be seen in this patient's condition?", "answer": "PCR positive for Chlamydia trachomatis", "options": {"A": "Gram-negative rods in school of fish formation on Gram stain", "B": "PCR positive for Chlamydia trachomatis", "C": "Positive RPR, VDRL, and FTA-ABS", "D": "Tzanck smear with multinucleated giant cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care provider", "evaluation", "painful mass", "left groin", "symptoms began 4 days", "painful mass", "slowly enlarged", "ruptured", "ulcerated", "denies fever", "chills", "dysuria", "hematuria", "Three weeks prior to", "current symptoms", "noted", "small", "painless ulcer", "labium majorum", "resolved", "days", "admits to", "sex", "male partner", "month", "traveling", "Southeast Asia", "Temperature", "blood pressure", "84 mmHg", "pulse", "76 min", "respirations", "min", "Physical examination", "significant", "left-sided", "tender", "ulcerative lymph nodes", "dark discoloration", "following", "most likely to", "seen", "patient", "ondition?"]}
{"question": "A 70-year-old hypertensive and hyperlipidemic woman comes to the emergency department with chief complaints of acute onset of impaired speech and comprehension with a right-sided weakness for the last 1.5 hours. The patient was on 2 antihypertensive medications and a statin, but she was not receiving any antiplatelet drugs. She has a blood pressure of 136/94, heart rate of 84/min, and respiratory rate of 15/min. Initial examination shows global aphasia, right homonymous hemianopia, and hemisensory loss. An acute ischemic stroke caused by distal left internal carotid artery occlusion with salvageable penumbral tissue is diagnosed based on a non-contrast CT scan, brain MRI, and catheter cerebral angiogram. Intravenous tissue plasminogen activator is given as treatment within 3 hours of presentation. Which of the following cellular processes is typical of the section of reversible injury noted in this patient?", "answer": "Decreased ATP", "options": {"A": "Mitochondrial permeability", "B": "Caspase activation", "C": "Lysosomal rupture", "D": "Decreased ATP"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["70 year old hypertensive", "woman", "emergency department", "chief complaints", "acute onset", "impaired speech", "comprehension", "right-sided weakness", "last", "hours", "patient", "2 antihypertensive medications", "statin", "not receiving", "antiplatelet drugs", "blood pressure", "heart rate", "84 min", "respiratory", "min", "Initial examination shows global aphasia", "right homonymous hemianopia", "hemisensory loss", "acute ischemic caused", "distal left internal carotid artery occlusion", "penumbral tissue", "diagnosed based", "non contrast CT scan", "brain MRI", "catheter cerebral angiogram", "Intravenous tissue plasminogen activator", "given", "treatment", "3 hours", "presentation", "following cellular processes", "typical", "section", "reversible injury noted", "patient"]}
{"question": "During the normal catabolism of protein, urea and ammonia are produced as waste products. If these waste products are not cleared by the liver and kidneys, hyperammonemia can occur, leading to confusion and delirium. Fortunately, a healthy liver can clear these waste products via the urea cycle. Which of the following reactions is the rate limiting step in this cycle?", "answer": "NH3 + HCO3- + 2 ATP --> carbamoyl phosphate + 2 ADP + Pi", "options": {"A": "NH3 + HCO3- + 2 ATP --> carbamoyl phosphate + 2 ADP + Pi", "B": "Carbamoyl phosphate + ornithine --> citrulline+ Pi", "C": "Citrulline + aspartate + ATP --> arginosuccinate + AMP + PPi", "D": "Arginine + H20 --> ornithine + urea"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["normal catabolism", "protein", "urea", "ammonia", "waste products", "waste products", "not cleared by", "liver", "kidneys", "hyperammonemia", "occur", "leading", "confusion", "delirium", "healthy liver", "clear", "waste products", "urea cycle", "following reactions", "rate limiting step", "cycle"]}
{"question": "A 46-year-old man presents with worsening pain in multiple joints for the past 2 weeks. He says the pain is most severe in the proximal parts of his fingers and his wrists, but it has now spread to his elbows, and, occasionally, his knees. He says the joint involvement is symmetric. He also complains of morning joint stiffness that improves with activity and reports feeling fatigued during the day. He started taking ibuprofen 2 months ago for the pain which initially subsided, but, over the last few weeks, it has worsened despite the medication. He was diagnosed with type 2 diabetes mellitus 1 year ago and has had difficulty controlling his blood glucose levels. The patient denies any smoking history, alcohol, or recreational drug use. A review of systems is significant for a weight loss of 3.0 kg (6.6 lb) over the last 3 months despite no change in diet or activity level. Which of the following is the most likely 1st-line medication in this patient?", "answer": "Methotrexate", "options": {"A": "Infliximab", "B": "Anakinra", "C": "Methotrexate", "D": "High-dose prednisone for 60 days"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "worsening pain", "multiple joints", "past 2 weeks", "pain", "most severe", "proximal parts of", "fingers", "wrists", "now spread", "elbows", "occasionally", "knees", "joint involvement", "symmetric", "morning joint stiffness", "improves", "activity", "reports feeling fatigued", "day", "started taking ibuprofen", "months", "pain", "initially", "last", "weeks", "worsened", "medication", "diagnosed", "type year", "difficulty controlling", "blood glucose levels", "patient denies", "smoking history", "alcohol", "recreational drug use", "review of systems", "significant", "weight loss of 3.0 kg", "6.6", "last", "months", "change", "diet", "activity level", "following", "most likely 1st line medication", "patient"]}
{"question": "A previously healthy 29-year-old woman, gravida 1, para 0, at 35 weeks' gestation comes to the physician for a routine prenatal visit. Current medications include folic acid and a multivitamin. A rectovaginal swab culture grows bacitracin-resistant colonies of gram-positive cocci with surrounding areas of clear hemolysis. Which of the following is the most appropriate intervention to decrease vertical transmission of this organism?", "answer": "Administer ampicillin intrapartum", "options": {"A": "Abstain from breastfeeding", "B": "Administer ampicillin intrapartum", "C": "Perform amniocentesis at 37 weeks", "D": "Administer intravenous immune globulin postpartum"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["healthy 29 year old woman", "gravida 1", "para 0", "35 weeks", "gestation", "physician", "routine prenatal visit", "Current medications include folic acid", "multivitamin", "rectovaginal swab culture", "bacitracin resistant colonies", "gram-positive cocci", "surrounding areas", "clear hemolysis", "following", "most appropriate intervention to decrease vertical transmission", "organism"]}
{"question": "A 2-year-old girl is brought in to the office by her parents. They state that their daughter has recently been more irritable than usual, and she occasionally becomes pale and blue. Her parents note that she was diagnosed with a heart murmur, but it was never treated. Physical examination reveals a small child in distress. She is laying on the examination table with her knees drawn to her chest. Cardiac auscultation reveals a harsh, systolic ejection murmur that is best heard at the upper left sternal border. Which of the following is the most likely diagnosis?", "answer": "Tetralogy of Fallot", "options": {"A": "Tetralogy of Fallot", "B": "Transposition of great vessels", "C": "Pulmonary hypoplasia", "D": "Atrial septal defect"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2 year old girl", "brought", "office", "parents", "state", "daughter", "recently", "more irritable than usual", "occasionally", "pale", "blue", "parents note", "diagnosed", "heart murmur", "never treated", "Physical examination reveals", "small child", "distress", "laying", "examination table", "knees drawn", "chest", "Cardiac auscultation reveals", "harsh", "systolic ejection murmur", "best heard", "upper left sternal border", "following", "most likely diagnosis"]}
{"question": "An 18-year-old male is brought in by fire rescue. The patient was an unrestrained passenger in a motor vehicle crash and was ejected from the vehicle after collision. Upon arrival to the trauma bay, the patient has a Glasgow coma scale (GCS) of 6. He is rapidly intubated, and vitals are a temperature of 99.5°F (37.5°C), pulse of 130 bpm, and blood pressure of 83/64 mmHg. He is noted to have multiple ecchymoses over his body, as well as petechiae and purpura. He has a laceration over his clavicle that continues to bleed despite a pressure bandage. Radiographs of his lower extremity show multiple long bone fractures. Two large bore IV lines are placed, and the patient oozes from around the sites of venepuncture. Labs are notable for a WBC of 20,000/mm^3, Hb of 10.1g/dL, platelets of 48,000/mm^3, and prolongation of the PT and aPTT. This patient's presentation can best be explained by which of the following diagnoses?", "answer": "Disseminated intravascular coagulation", "options": {"A": "Air embolization", "B": "Tension pneumothorax", "C": "Disseminated intravascular coagulation", "D": "Coagulopathy of trauma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male", "brought", "fire", "patient", "passenger", "motor vehicle crash", "vehicle", "collision", "arrival", "trauma bay", "patient", "Glasgow coma scale", "rapidly intubated", "temperature", "99", "pulse", "blood pressure", "83 64 mmHg", "noted to", "multiple ecchymoses", "body", "petechiae", "purpura", "laceration", "clavicle", "continues to bleed", "pressure bandage", "Radiographs", "lower extremity show multiple long bone fractures", "Two large bore IV lines", "placed", "patient", "sites of venepuncture", "Labs", "notable", "WBC", "20", "mm", "Hb", "10", "dL", "platelets", "48", "mm", "prolongation", "PT", "aPTT", "patient's presentation", "best", "following diagnoses"]}
{"question": "A 60-year-old man presents to his local walk-in clinic with 1 week of fever, chills, night sweats, anorexia, malaise, progressive shortness of breath, and sharp chest pain. He is found with a blood pressure of 100/80 mm Hg, a heart rate of 84/min, an elevated respiratory rate, and a holosystolic heart murmur III/VI. His palms and soles show non-tender erythematous lesions. His personal medical history is relevant for frequent visits to the ER for lower gastrointestinal bleeding in the last month with a recent colonoscopy that reported an ulcerative lesion suggestive of colorectal cancer. He has not been subjected to dental procedures recently, and he denies the use of psychoactive drugs. A chest plain film shows clear lungs and mild cardiomegaly, and echocardiography reports the presence of vegetations involving the mitral valve. Which of the following organisms is the most likely causative agent?", "answer": "Streptococcus bovis", "options": {"A": "Staphylococcus aureus", "B": "Escherichia coli", "C": "Haemophilus aphrophilus", "D": "Streptococcus bovis"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["60 year old man presents", "local walk-in clinic", "1 week", "fever", "chills", "night sweats", "anorexia", "malaise", "progressive shortness of breath", "sharp chest pain", "found", "blood pressure", "100 80 mm Hg", "heart rate", "84 min", "elevated respiratory rate", "holosystolic heart murmur III VI", "palms", "soles show non-tender erythematous lesions", "personal medical history", "relevant", "frequent visits", "ER", "lower gastrointestinal bleeding", "last month", "recent colonoscopy", "reported", "ulcerative lesion suggestive of colorectal cancer", "not", "subjected", "dental procedures recently", "denies", "use", "psychoactive drugs", "chest plain film shows clear lungs", "mild cardiomegaly", "echocardiography reports", "presence", "vegetations involving", "mitral valve", "following organisms", "most likely causative agent"]}
{"question": "A 31-year-old man with a history of schizophrenia is brought to the emergency department by police after being found agitated and attempting to steal from a grocery store. His past medical history is only notable for a recent office note from his primary care doctor for treatment of seasonal allergies. His temperature is 101°F (38.3°C), blood pressure is 173/97 mmHg, pulse is 105/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for a man who is very irritable and restless. He is not cooperative with exam or history and becomes combative requiring intramuscular medications and security restraining him. After this event, the rest of his exam is notable for 7 mm pupils which are equal and reactive to light, spontaneous movement of all limbs, normal sensation, and warm and sweaty skin. The patient is answering questions and states he wants to kill himself. Which of the following substances was most likely used by this patient?", "answer": "Cocaine", "options": {"A": "Alcohol", "B": "Cocaine", "C": "Diphenhydramine", "D": "Haloperidol"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["31 year old man", "history of schizophrenia", "brought", "emergency department", "police", "found agitated", "attempting", "steal", "grocery store", "past medical history", "only notable", "recent office note", "primary care doctor", "treatment", "seasonal allergies", "temperature", "3C", "blood pressure", "97 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "man", "very irritable", "restless", "not cooperative", "exam", "history", "combative", "intramuscular medications", "security restraining", "event", "rest", "exam", "notable", "mm pupils", "equal", "reactive to light", "spontaneous movement", "limbs", "normal sensation", "warm", "sweaty skin", "patient", "answering questions", "states", "to kill", "following substances", "most likely used by", "patient"]}
{"question": "A 40-year-old obese man presents to his primary care provider with a history of excessive daytime somnolence and easy fatigability. Upon further questioning, it is found that although his sleeping hours are adequate, he does not feel refreshed in the morning. His wife complains that he snores loudly all night. After ruling out common medical disorders and possible drug abuse, he is advised an overnight polysomnogram that records 12 episodes of apnea and 30 episodes of hypopnea during a 7-hour sleep. Which of the following statements best describes this patient’s condition?", "answer": "This patient's apnea-hypopnea index (AHI) is more than 5.", "options": {"A": "This patient's apnea-hypopnea index (AHI) is more than 5.", "B": "Episodes of apnea and hypopnea are more likely to occur during deeper stages of non-rapid eye movement sleep.", "C": "Mouth opening during sleep breaks the seal between the tongue and the teeth and relieves airway obstruction.", "D": "Gynoid obesity is associated with apnea and hypopnea more frequently as compared to android obesity."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old obese man presents", "primary care provider", "history", "excessive daytime somnolence", "easy fatigability", "further questioning", "found", "sleeping hours", "adequate", "not feel refreshed", "morning", "wife", "snores", "night", "ruling out common medical disorders", "possible drug abuse", "overnight polysomnogram", "records", "episodes of apnea", "30 episodes of hypopnea", "hour sleep", "following statements best", "patients condition"]}
{"question": "A 70-year-old man presents with cough and progressively worsening shortness of breath for the last 6 months. He feels short of breath even without exertion and states he ‘got winded’ while walking to his bedroom last night. He describes his cough as non-productive and says he can identify no recognizable triggers. No significant past medical history. The patient is a retired welder and has been living with his son since his wife passed away 5 years ago. He denies any smoking history or current alcohol or drug use. His vital signs include: pulse rate 72/min, respiratory rate 15/min, blood pressure 134/80 mm Hg, and temperature 36.8°C (98.0°F). On physical examination, digital clubbing is noted. Bilateral basilar fine crackles on noted on pulmonary auscultation. Expiratory flow rates are measured and found to be high when corrected for lung volume. A chest X-ray is performed and shown in the image below. Which of the following most likely accounts for the increased expiratory flow rate in this patient?", "answer": "Radial traction on airway wall", "options": {"A": "Anatomical dead space", "B": "Lung compliance", "C": "Radial traction on airway wall", "D": "Small airway wall thickness"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["70 year old man presents", "cough", "worsening shortness of breath", "last", "months", "feels short of breath", "exertion", "states", "got winded", "walking", "bedroom", "night", "cough", "non-productive", "triggers", "significant past medical history", "patient", "retired welder", "living", "son", "wife passed", "years", "denies", "smoking history", "current alcohol", "drug use", "vital signs include", "pulse rate 72 min", "respiratory rate", "min", "blood pressure", "80 mm Hg", "temperature 36", "98", "physical examination", "digital clubbing", "noted", "Bilateral basilar fine crackles", "noted", "pulmonary auscultation", "Expiratory flow rates", "measured", "found to", "high", "corrected", "lung volume", "chest X-ray", "performed", "shown", "image", "following", "likely accounts", "increased expiratory flow rate", "patient"]}
{"question": "Two hours following an elective cholecystectomy, a 43-year-old woman has fever and chills. The patient received cephalexin for antibiotic prophylaxis and one unit of packed red blood cells during the procedure. She underwent a hysterectomy 9 years ago for leiomyomata uteri. She has a 5-year history of hypertension treated with lisinopril. Her temperature is 39.5°C (102.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/90 mm Hg. Examination shows a mildly tender abdominal wound without erythema. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. She had a Foley catheter and peripheral line access placed at the time of the procedure. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Transfusion reaction", "options": {"A": "Adverse effect of medication", "B": "Malignant hyperthermia", "C": "Urinary tract infection", "D": "Transfusion reaction"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Two hours following", "elective cholecystectomy", "year old woman", "fever", "chills", "patient received cephalexin", "antibiotic prophylaxis", "one unit", "packed red blood cells", "procedure", "hysterectomy", "years", "leiomyomata uteri", "5 year history of hypertension treated with lisinopril", "temperature", "pulse", "90 min", "respirations", "min", "blood pressure", "90 mm Hg", "Examination shows", "mildly tender abdominal", "erythema", "lungs", "clear", "auscultation", "Cardiac shows", "abnormalities", "Foley catheter", "peripheral line access placed", "time", "procedure", "following", "most likely cause", "patient's symptoms"]}
{"question": "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?", "answer": "Oral morphine therapy", "options": {"A": "Oral morphine therapy", "B": "Intravenous ampicillin and gentamicin combination therapy", "C": "Oral methimazole therapy", "D": "Dextrose infusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["first 24 hours", "delivery", "g", "male newborn", "not feeding well", "high-pitched cry", "diaphoretic", "born", "weeks", "gestation", "30 year old woman", "gravida 2", "para 1", "uncomplicated labor", "delivery", "Apgar scores", "5 minutes", "mother", "not receive prenatal care", "takes codeine syrup frequently", "dry cough", "infant's temperature", "pulse", "min", "blood pressure", "83 50 mm Hg", "Examination shows hyperreflexia", "tremors", "excessive startle response", "baby", "to prevent excoriations", "fluid resuscitation", "initiated", "Complete blood count", "serum levels", "glucose", "bilirubin", "calcium", "normal limits", "most appropriate next step", "treatment", "newborn"]}
{"question": "A 38-year-old woman with a history of systemic lupus erythematosus, obesity, and hyperlipidemia presents to her primary care physician for evaluation of new bilateral blisters on her hands. She says that she first noticed these blisters shortly after returning from a weekend trip to the beach two weeks prior. She denies any fevers, joint pains, or other skin rash during this period. The patient works in the adult entertainment industry. On examination, there are multiple flaccid blisters of the bilateral dorsal hands with hemorrhagic crusts, mild scarring, and hyperpigmentation. In addition, increased hair growth is noted on the bilateral malar cheeks. Her temperature is 99.1° F (37.3° C), pulse is 95/min, blood pressure is 130/87 mmHg, respirations are 13/min, and oxygen saturation is 98% on room air. Her laboratory results are:\n\nSerum:\nNa+: 140 mEq/L\nK+: 4.5 mEq/L\nCl-: 100 mEq/L\nHCO3-: 21 mEq/L\nBUN: 20 mg/dL\nCreatinine: 1.1 mg/dL\nGlucose: 104 mg/dL\n\nLeukocyte count: 9,000/mm^3\nHemoglobin: 12.4 g/dL\nPlatelets: 400,000/mm^3\n\nAnti-nuclear antibody titer 1:320\n\nWhich of the following would confirm the diagnosis in this patient?", "answer": "Urine porphyrin levels", "options": {"A": "Anti dsDNA titers", "B": "Anti-hemidesmosome titers", "C": "Urine porphyrin levels", "D": "Tzanck smear"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "history of systemic lupus erythematosus", "obesity", "hyperlipidemia presents", "primary care physician", "evaluation", "new bilateral blisters", "hands", "first", "blisters", "returning", "weekend trip", "beach two weeks prior", "denies", "fevers", "joint pains", "skin rash", "period", "patient works", "adult entertainment industry", "examination", "multiple flaccid blisters of", "bilateral dorsal hands", "hemorrhagic crusts", "mild scarring", "hyperpigmentation", "addition", "increased hair growth", "noted", "bilateral malar", "temperature", "99", "F", "pulse", "95 min", "blood pressure", "87 mmHg", "respirations", "min", "oxygen saturation", "98", "room air", "laboratory results", "Serum", "Na", "mEq/L K", "4.5 mEq/L Cl", "100 mEq/L HCO3", "mEq/L", "20 mg/dL Creatinine", "1.1 mg/dL Glucose", "mg/dL", "Leukocyte count", "mm", "Hemoglobin", "12.4 g/dL Platelets", "400", "mm", "Anti-nuclear antibody titer 1 320", "following", "confirm", "diagnosis", "patient"]}
{"question": "A 64-year-old man presents with severe respiratory distress. This has onset over the past 3 weeks, progressively worsening. Past history involves congestive heart failure (CHF). Due to concerns of concurrent pneumonia, sputum studies are ordered. Microscopic examination of his sputum demonstrates heart failure cells (hemosiderin-containing macrophages). Which of the following cellular organelles is significant in the formation of these cells?", "answer": "Lysosomes", "options": {"A": "Endoplasmic reticulum (ER)", "B": "Ribosomes", "C": "Lysosomes", "D": "Mitochondria"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["64 year old man presents", "severe respiratory distress", "onset", "past", "weeks", "worsening", "Past history", "congestive heart failure", "Due to concerns", "concurrent pneumonia", "sputum studies", "ordered", "Microscopic examination", "sputum demonstrates heart failure cells", "hemosiderin containing macrophages", "following cellular organelles", "significant", "formation", "cells"]}
{"question": "A previously healthy 52-year-old woman is brought to the emergency department after sustaining burns over 45% of her body in a house fire. On arrival, she is in acute distress but is fully oriented. Aggressive intravenous fluid resuscitation is begun and the patient is transferred to the intensive care unit of a burn center. 20 hours later, she has several large, tarry black stools and develops hypotension and tachycardia. Despite appropriate lifesaving measures, she dies. Which of the following is the most likely underlying cause of the patient's tarry black stools?", "answer": "Decreased gastric blood flow", "options": {"A": "Decreased prostaglandin synthesis", "B": "Erosion of tortuous submucosal arteriole", "C": "Bacterial colonization of the gastric antrum", "D": "Decreased gastric blood flow"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["healthy", "year old woman", "brought", "emergency department", "sustaining burns", "body", "house fire", "arrival", "acute distress", "oriented", "Aggressive intravenous", "begun", "patient", "transferred", "intensive care unit", "burn center", "20 hours later", "several large", "tarry black stools", "hypotension", "tachycardia", "appropriate lifesaving measures", "following", "most likely underlying cause", "patient's tarry black stools"]}
{"question": "A 45-year-old man presents to his primary care provider after feeling sad and depressed for the past several months. His wife divorced him about 6 months ago and took the kids and moved out of state. Since then he has had difficulty waking up in the morning and getting to work on time. He takes some comfort in food and has gained about 9.1 kg (20 lb). He eats out several times a week and sometimes consumes 2 whole meals in one sitting. Other than this new obsession with eating large quantities of food and excess sleeping he no longer enjoys doing things he liked doing in the past. Besides eating and sleeping he is always excited to see his children and looks forward to their visits. He says it's the one thing keeping him going. Additionally, he does not feel like he has the same drive or focuses at work. He reports that he has no interest in hurting himself or others. His blood pressure is 119/81 mm Hg, pulse rate is 85/min, respiratory rate is 12/min, and the temperature is 36.8°C (98.2°F). His physical exam is normal. What other symptom is most likely present in this patient?", "answer": "Leaden paralysis", "options": {"A": "Leaden paralysis", "B": "Depressive symptoms that are worse in the morning", "C": "Stereotypies", "D": "Mania"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man presents", "primary care provider", "feeling sad", "depressed", "past", "months", "wife divorced", "about", "months", "took", "kids", "moved out", "state", "Since then", "difficulty waking", "morning", "getting to work on time", "takes", "comfort", "food", "gained", "kg", "20", "eats out", "times", "week", "sometimes", "2 whole meals", "one sitting", "Other", "new obsession", "eating large quantities of food", "excess sleeping", "longer", "things", "liked", "past", "eating", "sleeping", "always excited to see", "children", "looks forward", "visits", "one thing keeping", "not feel", "same drive", "focuses", "work", "reports", "interest", "others", "blood pressure", "81 mm Hg", "pulse rate", "85 min", "respiratory rate", "min", "temperature", "36", "98", "physical exam", "normal", "symptom", "most likely present", "patient"]}
{"question": "A 35-year-old man comes to the emergency department with acute shortness of breath that developed after a 10-hour international flight. His pulse is 124/min and pulse oximetry on room air shows an oxygen saturation of 90%. He weighs 50-kg (110-lb). A diagnosis of pulmonary embolism is suspected and intravenous heparin is initiated. If the volume of distribution of heparin is equivalent to 60 mL/kg and the target peak plasma concentration is 0.5 units/mL, which of the following is the most appropriate loading dose for this patient?", "answer": "1,500 units", "options": {"A": "3,000 units", "B": "1,500 units", "C": "6,000 units", "D": "Cannot be calculated, as bioavailability is not known"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old man", "emergency department", "acute shortness of breath", "10 hour international flight", "pulse", "min", "pulse oximetry", "room air shows", "oxygen", "90", "50 kg", "diagnosis", "pulmonary embolism", "suspected", "intravenous heparin", "initiated", "volume of distribution", "heparin", "equivalent", "60 mL/kg", "target peak plasma", "0.5 units/mL", "following", "most appropriate loading dose", "patient"]}
{"question": "A 45-year-old man presents to a surgeon with painless swelling over his right leg. He noticed the swelling 6 months ago, but he ignored it because it was painless. However, he is now concerned as the swelling has been increasing in size over the last 6 months. He also mentions that his father and brother have lipomas over the extremities. On physical examination, the swelling is well-circumscribed and non-tender, measuring approximately 4 x 5 cm. After evaluation, the surgeon performs a surgical resection of the tumor and sends the tissue for histopathological examination. The pathologist reports the tumor to be a liposarcoma rather than a lipoma. Which of the following enzymes is most likely to show increased activity in the cells of this patient’s tumor?", "answer": "Telomerase", "options": {"A": "Alkaline phosphatase", "B": "RNase", "C": "Superoxide dismutase", "D": "Telomerase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "surgeon", "painless swelling", "right", "swelling", "months", "ignored", "painless", "now concerned", "swelling", "increasing in size", "last", "months", "father", "brother", "lipomas", "extremities", "physical examination", "swelling", "well circumscribed", "non-tender", "measuring approximately", "evaluation", "surgeon performs", "surgical resection", "tumor", "sends", "tissue", "histopathological examination", "pathologist reports", "tumor to", "liposarcoma", "lipoma", "following enzymes", "most likely to show increased activity", "cells", "patients tumor"]}
{"question": "A 24-year-old woman presents to her primary care physician for a wellness visit. She says that she has been generally healthy but has noticed difficulty concentrating, becoming increasingly fatigued, and a 15-pound weight increase over the course of a few months. She also reports mild constipation and joint pain. Approximately 6-months ago, she experienced palpitations, increased stool frequency, and a hand tremor. Her past medical history is significant for asthma. Her father is not living and had Parkinson disease, and her mother has poorly controlled rheumatoid arthritis. She is currently sexually active in a monogamous relationship and uses contraception consistently. She denies cigarette smoking and occasionally drinks wine. She experimented once with lysergic acid diethylamide 6 years ago. Her temperature is 99°F (37.2°C), blood pressure is 127/98 mmHg, pulse is 55/min, and respirations are 13/min. On physical exam, the patient has slow speech and movement. She has tenderness to palpation of her wrist and ankle joints. She has delayed relaxation of deep tendon reflexes. Which of the following will most likely be found in this patient?", "answer": "Elevated TSH", "options": {"A": "Elevated TSH", "B": "High Patient Health Questionnaire-9 (PHQ-9) score", "C": "Positive anti-CCP antibodies", "D": "Positive urine toxicology"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "primary care physician", "wellness visit", "healthy", "difficulty concentrating", "fatigued", "pound weight increase", "course", "months", "reports mild constipation", "joint pain", "Approximately", "months", "experienced palpitations", "increased stool frequency", "hand tremor", "past medical history", "significant", "asthma", "father", "not living", "Parkinson disease", "mother", "poorly controlled rheumatoid arthritis", "currently sexually active", "monogamous relationship", "uses contraception", "denies cigarette smoking", "occasionally drinks wine", "experimented", "lysergic acid diethylamide", "years", "temperature", "blood pressure", "98 mmHg", "pulse", "55 min", "respirations", "min", "physical exam", "patient", "slow speech", "movement", "tenderness", "palpation", "wrist", "ankle joints", "delayed relaxation", "deep tendon reflexes", "following", "most likely", "found", "patient"]}
{"question": "A 3466-g (7-lb, 10-oz) female newborn is delivered at 38 weeks' gestation to a 32-year-old woman, gravida 2, para 1. Apgar scores are 7 and 8, at 1 and 5 minutes, respectively. The mother has a history of schizophrenia and was treated with lithium until 5 weeks' gestation, when she found out that she was pregnant. The mother was treated for alcohol abuse disorder 2 years ago. She has been sober for 14 months now. Examination shows that the child has micrognathia, a broad nasal bridge, a short philtrum, and small, low-set ears. Examination of the mouth shows a cleft palate. A grade 3/6 systolic ejection murmur can be heard over the left sternal border. Echocardiography shows a single overriding great vessel arising from the heart. Further evaluation is most likely to show which of the following findings?", "answer": "Low levels of parathyroid hormone in serum", "options": {"A": "Low levels of parathyroid hormone in serum", "B": "Double bubble sign on abdominal x-ray", "C": "Chromosome 5p deletion on FISH studies", "D": "Bilateral cataracts on ocular examination"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["g", "10 oz", "female newborn", "delivered", "weeks", "gestation", "year old woman", "gravida 2", "para 1", "Apgar scores", "at 1", "5 minutes", "mother", "history of schizophrenia", "treated with lithium", "5 weeks", "gestation", "found out", "pregnant", "mother", "treated", "alcohol abuse disorder", "years", "sober", "months now", "Examination shows", "child", "micrognathia", "broad nasal bridge", "short philtrum", "small", "low-set ears", "Examination of", "mouth shows", "cleft palate", "grade", "systolic ejection murmur", "heard", "left sternal border", "Echocardiography shows", "single overriding great vessel arising", "heart", "Further evaluation", "most likely to show", "following findings"]}
{"question": "A 10-year-old boy is brought to his pediatrician after discovering a painless mass in the left testicle. Results from tumor markers and a biopsy are as follows:\nAFP 350 ng/mL (normal value < 10 ng/mL)\nhCG 0.4 IU/L (normal value < 0.5 IU/L)\nBiopsy: Presence of glomeruli-like structures with a central capillary within a mesodermal core, lined by flattened layers of germ cells.\nWhat is the most likely diagnosis in this patient?", "answer": "Yolk sac tumor", "options": {"A": "Classic seminoma", "B": "Choriocarcinoma", "C": "Teratoma", "D": "Yolk sac tumor"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["A 10 year old boy", "brought", "pediatrician", "discovering", "painless mass", "left testicle", "Results", "tumor markers", "biopsy", "follows", "350 ng/mL", "normal value", "10 ng/mL", "hCG 0.4 IU/L", "normal value", "0.5 IU L", "Biopsy", "Presence", "glomeruli", "structures", "central capillary", "mesodermal core", "lined", "flattened layers", "germ cells", "most likely diagnosis", "patient"]}
{"question": "An 80-year-old man presents with severe pain of the right lower extremity. He says that symptoms had an acute onset while he was in the ICU for a COPD exacerbation due to a recent upper respiratory infection, which was treated with nebulized albuterol and ipratropium bromide, continuous oxygen, IV methylprednisolone, and levofloxacin. He says he has been hospitalized 3 other times this year for COPD exacerbations. The medical history is significant for a left main coronary artery myocardial infarction after a coronary artery bypass graft (CABG) 2 months ago, mild cognitive impairment, and type 2 diabetes mellitus. Current medications are metformin, aspirin, clopidogrel, metoprolol, atorvastatin, galantamine, and enalapril. He reports a 40-pack-year smoking history but quit 10 years ago. His temperature is 39.0°C (102.5°F); blood pressure is 100/75 mm Hg; pulse is 122/min; respiratory rate is 20/min, and oxygen saturation is 88% on room air. The physical examination is significant for the cutaneous finding shown in the picture. The involved area is severely tender to palpation and there are warmth and crepitus. A foul-smelling discharge is also noted. Pain seems out of proportion to the exam findings. Which of the following is the next best step in management?", "answer": "Immediate debridement and empiric IV antibiotics", "options": {"A": "Immediate debridement", "B": "Immediate debridement and empiric IV antibiotics", "C": "Biopsy of wound", "D": "Contrast CT of the chest and abdomen"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["80 year old man presents", "severe pain", "right lower extremity", "symptoms", "acute onset", "ICU", "COPD exacerbation due to", "recent upper respiratory infection", "treated with nebulized albuterol", "ipratropium bromide", "continuous oxygen", "IV methylprednisolone", "levofloxacin", "hospitalized 3", "times", "year", "COPD exacerbations", "medical history", "significant", "left main coronary artery myocardial infarction", "coronary artery bypass graft", "months", "mild cognitive impairment", "type 2 diabetes mellitus", "Current medications", "metformin", "aspirin", "clopidogrel", "metoprolol", "atorvastatin", "galantamine", "enalapril", "reports", "40 pack-year smoking history", "quit 10 years", "temperature", "blood pressure", "100 75 mm Hg", "pulse", "min", "respiratory rate", "20 min", "oxygen saturation", "88", "room air", "physical examination", "significant", "cutaneous finding shown", "picture", "involved area", "severely tender", "palpation", "warmth", "crepitus", "smelling discharge", "noted", "Pain", "out", "proportion", "exam findings", "following", "next best step", "management"]}
{"question": "A 35-year-old woman presents to the emergency department after losing consciousness at work. On presentation, she is found to be somnolent though she is able to be woken by vocal stimuli. She says that over the last 12 hours, she has been experiencing muscle spasms, blurred vision, dry mouth, and hallucinations. She says that the symptoms started after she went on a hike in the woods and foraged from plants along the way. Physical exam reveals dry red skin and enlarged pupils. Her bladder is also found to be completely full though she says she is unable to urinate. Which of the following drugs would most likely be administered to this patient to treat her symptoms?", "answer": "Physostigmine", "options": {"A": "Atropine", "B": "Physostigmine", "C": "Pyridostigmine", "D": "Neostigmine"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old woman presents", "emergency department", "consciousness", "work", "presentation", "found to", "somnolent", "able to", "woken", "vocal stimuli", "last 12 hours", "experiencing muscle spasms", "blurred vision", "dry mouth", "hallucinations", "symptoms started", "woods", "plants", "Physical exam reveals dry red", "enlarged pupils", "bladder", "found to", "completely full", "unable to", "following drugs", "most likely", "administered", "patient to treat", "symptoms"]}
{"question": "A 34-year-old woman presents to the plastic surgery office 3 months following a rhinoplasty procedure. The patient has been recovering well. However, she has noticed a small whistling noise when she respires through her nose, which you appreciate on physical exam. Which of the following is the most likely cause of this phenomenon?", "answer": "A septal hematoma causing a perforation", "options": {"A": "Post-operative swelling", "B": "A septal hematoma causing a perforation", "C": "A deviated septum that is now straight, resulting in altered nasal airflow", "D": "Excessive columellar show resulting in increased nasal airflow"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "plastic surgery office 3 months following", "rhinoplasty procedure", "patient", "recovering well", "small whistling noise", "nose", "physical exam", "following", "most likely cause", "phenomenon"]}
{"question": "A 43-year-old woman comes to the physician because of a 1-day history of rash on the trunk and lower extremities. Three days ago, she visited a spa resort with multiple swimming pools and whirlpools. A friend of hers who also visited the spa has developed a similar rash. She does not smoke or drink alcohol and takes no medications. She appears well. Her vital signs are within normal limits. Examination shows multiple erythematous, excoriated papules and pustules over the trunk and upper thighs. The inflammation seen in this patient's condition most likely originated in which of the following parts of the skin?", "answer": "Hair follicles", "options": {"A": "Superfical epidermis", "B": "Hair follicles", "C": "Papillary dermis", "D": "Eccrine sweat glands"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "1-day history", "rash", "trunk", "lower extremities", "Three days", "visited", "spa resort", "multiple swimming pools", "whirlpools", "friend", "visited", "spa", "similar rash", "not smoke", "drink alcohol", "takes", "medications", "appears well", "vital signs", "normal limits", "Examination shows multiple erythematous", "excoriated papules", "pustules", "trunk", "upper thighs", "inflammation seen", "patient's condition", "likely", "following parts", "skin"]}
{"question": "A 19-year-old man is brought to the emergency department because of severe right shoulder pain and inability to move the shoulder after a fall while climbing outdoors. Examination shows the right upper extremity is externally rotated and slightly abducted. There is loss of the the normal rounded appearance of the shoulder. The right humeral head is palpated below the coracoid process. Sensation to pinprick over which of the following skin areas is most likely to be reduced?", "answer": "Lateral aspect of the shoulder", "options": {"A": "Medial aspect of the upper arm", "B": "Lateral aspect of the shoulder", "C": "Skin above the clavicle", "D": "Dorsal aspect of forearm and hand"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "severe right shoulder pain", "to move", "shoulder", "fall", "climbing outdoors", "Examination shows", "right upper extremity", "externally rotated", "slightly", "loss", "normal rounded appearance", "shoulder", "right humeral head", "palpated", "coracoid process", "Sensation", "pinprick", "following skin areas", "most likely to", "reduced"]}
{"question": "A 25-year-old girl is brought to the emergency room after a suicide attempt. Her mother states that she found a large empty pill bottle next to her. The patient is conscious and tearful. She is currently complaining of severe abdominal pain but refuses to give any other history. She has a blood pressure of 135/86, respiratory rate of 18/min, and heart rate of 86/min. On examination, her abdomen is exquisitely tender with evidence of crepitus in the epigastric region. Abdominal CT reveals a gastric perforation. Which of the following is the most likely cause?", "answer": "Decreased production of PGE2", "options": {"A": "Decreased production of PGE2", "B": "Buildup of a toxic metabolite due to kidney disease", "C": "Increased stimulation of the vagus nerve", "D": "Hypovolemia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl", "brought", "emergency room", "suicide attempt", "mother states", "found", "large empty pill bottle next to", "patient", "conscious", "tearful", "currently", "severe abdominal", "refuses to give", "history", "blood pressure", "respiratory rate", "min", "heart rate", "min", "examination", "abdomen", "tender", "evidence", "crepitus", "epigastric region", "Abdominal CT reveals", "gastric perforation", "following", "most likely cause"]}
{"question": "A 32-year-old male presents to the ED with acute-onset chest pain. His blood pressure is 157/90 mmHg and his his pulse is 116/min. He appears anxious and agitated and a careful exam reveals dilated pupils and a perforated nasal septum. An EKG reveals ST segment elevation so he is urgently taken for cardiac intervention. Upon review, this patient reveals that he has not had care from a physician since he graduated from college. In the interim he has been largely unemployed and admits that he has recently been homeless. When asked directly, the patient admits to alcohol and marijuana use but denies illicit drug use. Which of the following best describes the mechanism of action of the agent most likely responsible for this patient's presentation?", "answer": "Blocking reuptake of dopamine and norepinephrine", "options": {"A": "Blocking reuptake of dopamine and norepinephrine", "B": "Inhibiting breakdown of biogenic amines", "C": "Antagonizing the NMDA receptor", "D": "Inhibiting the GABA receptor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "ED", "acute chest", "blood pressure", "90 mmHg", "pulse", "min", "appears anxious", "agitated", "careful exam reveals dilated pupils", "perforated nasal septum", "EKG reveals ST segment elevation", "taken", "cardiac intervention", "review", "patient reveals", "not", "care", "physician", "graduated", "college", "interim", "unemployed", "admits", "recently", "homeless", "directly", "patient admits", "alcohol", "marijuana use", "denies illicit drug use", "following best", "mechanism of action", "agent", "likely responsible", "patient's presentation"]}
{"question": "A 38-year-old woman comes to the physician because of difficulty falling asleep for the past 2 months. She wakes up frequently during the night and gets up earlier than desired. She experiences discomfort in her legs when lying down at night and feels the urge to move her legs. The discomfort resolves when she gets up and walks around or moves her legs. She has tried an over-the-counter sleep aid that contains diphenhydramine, which worsened her symptoms. She exercises regularly and eats a well-balanced diet. She admits that she has been under a lot of stress lately. Her brother has similar symptoms. The patient appears anxious. Physical examination shows no abnormalities. A complete blood count and iron studies are within the reference range. Which of the following is the most appropriate pharmacotherapy for this patient's symptoms?", "answer": "Pramipexole", "options": {"A": "Amitryptiline", "B": "Pramipexole", "C": "Codeine", "D": "Escitalopram"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of difficulty falling asleep", "past", "months", "wakes up frequently", "night", "gets", "earlier", "desired", "experiences discomfort", "legs", "lying", "night", "feels", "to move", "legs", "discomfort resolves", "gets", "walks", "moves", "legs", "over-the-counter sleep aid", "contains diphenhydramine", "worsened", "symptoms", "exercises", "eats", "well balanced diet", "admits", "lot", "stress", "brother", "similar symptoms", "patient appears anxious", "Physical examination shows", "abnormalities", "complete blood count", "iron studies", "reference range", "following", "most appropriate pharmacotherapy", "patient's symptoms"]}
{"question": "A 55-year-old woman is brought to the emergency department because of worsening upper abdominal pain for the past 8 hours. She reports that the pain radiates to her back and is associated with nausea. She has hypertension and hyperlipidemia, for which she takes enalapril, furosemide, and simvastatin. Her temperature is 37.5°C (99.5°F), blood pressure is 84/58 mm Hg, and pulse is 115/min. The lungs are clear to auscultation. Examination shows abdominal distention with epigastric tenderness and guarding. Bowel sounds are decreased. Extremities are warm. Laboratory studies show:\nHematocrit 48%\nLeukocyte count 13,800/mm3\nPlatelet count 175,000/mm3\nSerum  \nCalcium 8.0 mg/dL\nUrea nitrogen 32 mg/dL\nAmylase 250 U/L\nAn ECG shows sinus tachycardia. Which of the following is the most likely underlying cause of this patient's vital sign abnormalities?", "answer": "Capillary leakage", "options": {"A": "Abnormal coagulation and fibrinolysis", "B": "Capillary leakage", "C": "Decreased cardiac output", "D": "Pseudocyst formation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["55 year old woman", "brought", "emergency department", "of worsening upper abdominal pain", "past 8 hours", "reports", "pain radiates", "back", "associated with nausea", "hypertension", "hyperlipidemia", "takes enalapril", "furosemide", "simvastatin", "temperature", "99", "blood pressure", "84 58 mm Hg", "pulse", "min", "lungs", "clear", "auscultation", "Examination shows abdominal distention", "epigastric tenderness", "guarding", "Bowel sounds", "decreased", "Extremities", "warm", "Laboratory studies show", "Hematocrit 48", "Leukocyte count 13 800 mm3 Platelet count", "Serum", "mg/dL Urea nitrogen", "Amylase", "U/L", "ECG shows sinus tachycardia", "following", "most likely underlying cause", "patient's vital sign abnormalities"]}
{"question": "A 3-year-old boy is brought to his pediatrician for evaluation because his parents have been concerned by a number of troubling signs. Specifically, they have noticed that he has been exhibiting aggressive behavior as well as hyperactivity. In addition, he has had intellectual disability and is slow to hit developmental milestones. Physical exam reveals coarse facies, short stature, and joint stiffness. Eye exam reveals no abnormalities of the cornea or lens. Based on these findings, the patient is referred to a geneticist for further evaluation. Which of the following substances would most likely accumulate in the cells of this patient?", "answer": "Heparan sulfate", "options": {"A": "Cerebroside sulfate", "B": "Galactocerebroside", "C": "Heparan sulfate", "D": "Sphingomyelin"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy", "brought", "pediatrician", "evaluation", "parents", "concerned", "number", "signs", "exhibiting aggressive behavior", "hyperactivity", "addition", "intellectual disability", "slow to hit developmental milestones", "Physical exam reveals coarse facies", "short stature", "joint stiffness", "Eye exam reveals", "abnormalities of the cornea", "lens", "Based", "findings", "patient", "referred", "geneticist", "further evaluation", "following substances", "most likely", "cells", "patient"]}
{"question": "A 21-year-old man with a past medical history significant for Down syndrome presents to the outpatient primary care clinic for a routine follow up and high risk screening. He is relatively high functioning and currently has no additional significant medical conditions. He feels well and a physical examination shows that he is within normal limits. He denies any current tobacco use, alcohol use, or illicit drug use. His vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 17/min. When considering possible conditions for which this patient is predisposed, which of the following neoplasms is associated with Down syndrome?", "answer": "Acute lymphocytic leukemia", "options": {"A": "Gastric adenocarcinoma", "B": "Astrocytoma and cardiac rhabdomyoma", "C": "Esophageal adenocarcinoma", "D": "Acute lymphocytic leukemia"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["21-year-old man", "past medical history significant", "Down syndrome presents", "outpatient primary care clinic", "routine follow up", "high risk screening", "high functioning", "currently", "additional significant medical conditions", "feels well", "physical examination shows", "normal limits", "denies", "current tobacco use", "alcohol use", "illicit drug use", "vital signs include", "temperature", "36", "98", "blood pressure", "74 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "considering possible conditions", "patient", "predisposed", "following neoplasms", "associated with Down syndrome"]}
{"question": "A 35-year-old woman presents to the office because she has felt a small painless mass in her neck which has been slowly growing. She has no relevant past medical history. Her vital signs are within normal limits. On physical exam of the thyroid gland, a solitary nodule is palpated. It is fixed to the surrounding tissues and nontender. TSH is normal, and antithyroid antibodies are negative. Which of the following is the most likely cause of this patient’s symptoms?", "answer": "Papillary carcinoma", "options": {"A": "Endemic goiter", "B": "Follicular carcinoma", "C": "Hashimoto thyroiditis", "D": "Papillary carcinoma"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old woman presents", "office", "felt", "small painless mass", "neck", "slowly", "relevant past medical history", "vital signs", "normal limits", "physical exam", "thyroid gland", "solitary nodule", "palpated", "fixed", "surrounding tissues", "nontender", "normal", "antithyroid antibodies", "negative", "following", "most likely cause", "patients symptoms"]}
{"question": "A 4-year-old boy presents to the pediatrician’s office. His mother complains that he has been sleeping poorly, and she has noticed that he often scratches his perianal area. A scotch tape test is found to be positive and mebendazole is prescribed. Into which of the following subsets have the naïve T cells (TH0) developed due to the infection in this patient?", "answer": "TH2 cells", "options": {"A": "TH1 cells", "B": "TH2 cells", "C": "TH17", "D": "T0 cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 year old boy presents", "pediatricians office", "mother", "sleeping poorly", "often scratches", "perianal area", "scotch tape test", "found to", "positive", "mebendazole", "prescribed", "following subsets", "T cells", "TH0", "due to", "infection", "patient"]}
{"question": "A 69-year-old right-handed man comes to the physician for a routine health maintenance examination. On questioning, he has had some difficulty speaking for 3 months. During a conversation, he often has difficulty repeating what his interlocutor has said. He has hypertension and takes hydrochlorothiazide. His vital signs are within normal limits. The patient speaks fluently in full sentences and demonstrates normal comprehension. When asked to say the word “kindergarten,” he replies with, “Sintelmarvin… no, that's wrong…kinterflargin, no that isn't it either...kantolargen...no? How about, kindergarten?” The most likely cause of the patient's symptoms is occlusion of a branch of which of the following arteries?", "answer": "Left middle cerebral", "options": {"A": "Left middle cerebral", "B": "Right vertebral", "C": "Left posterior inferior cerebellar", "D": "Left penetrating"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["69 year old right-handed man", "physician", "routine health maintenance examination", "questioning", "difficulty speaking", "months", "conversation", "often", "difficulty repeating", "hypertension", "takes hydrochlorothiazide", "vital signs", "normal limits", "patient speaks", "full sentences", "demonstrates normal comprehension", "to", "word kindergarten", "kindergarten", "most likely cause", "patient's symptoms", "occlusion", "branch", "following arteries"]}
{"question": "An investigator is studying the frequency of polycythemia in a population of a remote, mountainous region. A representative sample of 100 men shows a normal distribution of hemoglobin concentration with a mean concentration of 17 g/dL and a standard error of 0.1 g/dL. Which of the following best represents the probability that a subject will have a hemoglobin concentration greater than 18 g/dL?", "answer": "15%", "options": {"A": "30%", "B": "15%", "C": "95%", "D": "99%"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["investigator", "studying", "frequency", "polycythemia", "population", "remote", "mountainous region", "representative sample", "100 men shows a normal distribution", "hemoglobin concentration", "mean concentration", "17 g dL", "standard error", "0.1 g/dL", "following best represents", "probability", "subject", "hemoglobin concentration greater than", "g/dL"]}
{"question": "A 57-year-old woman comes to the physician because of a 3-month history of fatigue. She also reports generalized itchiness that started approximately 2 months ago. Two weeks ago, she noticed yellowing of her eyes. She does not smoke or drink alcohol. She uses eyedrops for persistent dryness of the eyes. Her vital signs are within normal limits. Physical examination shows jaundice of the conjunctivae and skin. The mucous membranes of the mouth are dry. The abdomen is soft. The liver edge is palpable 3 cm below the right costal margin. There are generalized skin excoriations. Laboratory studies show:\nHemoglobin 15 g/dL\nLeukocyte count 7,700/mm3\nPlatelet count 332,000/mm3\nSerum\nGlucose 122 mg/dL\nTotal bilirubin 3.1 mg/dL\nDirect 2.5 mg/dL\nAlkaline phosphatase 452 U/L\nAST 155 U/L\nALT 168 U/L\nHepatitis B surface antigen negative\nHepatitis B core IgM antibody negative\nHepatitis B surface antibody positive\nHepatitis C antibody negative\nUltrasonography of the abdomen shows mildly increased echogenicity of the liver. Which of the following additional findings is most likely to be found in this patient?\"", "answer": "Cutaneous xanthomas", "options": {"A": "Inferior vena cava thrombosis", "B": "Cutaneous xanthomas", "C": "Increased CA 19-9 levels", "D": "Kayser-Fleischer rings\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["57 year old woman", "physician", "3 month history", "fatigue", "reports generalized itchiness", "started approximately", "months", "Two weeks", "yellowing", "eyes", "not smoke", "drink alcohol", "uses eyedrops", "persistent dryness of", "eyes", "vital signs", "normal limits", "Physical examination shows jaundice", "conjunctivae", "skin", "mucous membranes of", "mouth", "dry", "abdomen", "soft", "liver edge", "palpable 3 cm", "right costal margin", "generalized skin excoriations", "Laboratory studies show", "Hemoglobin", "g", "Leukocyte", "Platelet", "Serum", "mg", "Total bilirubin", "1 mg", "Direct 2.5 mg", "Alkaline phosphatase", "L AST", "ALT", "Hepatitis B", "core", "antibody", "positive", "Ultrasonography", "abdomen shows mildly increased echogenicity", "liver", "following additional findings", "most likely to", "found", "patient"]}
{"question": "A 32-year-old pregnant woman presents to her physician with flu-like symptoms for the past 3 days. She has a runny nose, mild headache, and feels achy. She has a mild fever and diffuse rash over her body. She is concerned about the health of her baby and wants to know if there are any medications that will make her feel better in a short time. Currently, she is at her 29th week of gestation and has received the tetanus vaccination as part of the antenatal care program she received since she immigrated at the end of her first trimester from Romania. She is otherwise healthy. Considering this patient, she is at a higher risk of giving birth to a newborn who will present with which of the following options?", "answer": "Wide pulse pressure", "options": {"A": "Single S2", "B": "Wide pulse pressure", "C": "Brachial-femoral delay", "D": "Tricuspid valve regurgitation"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old pregnant woman presents", "physician", "flu-like symptoms", "past 3 days", "runny nose", "mild headache", "feels achy", "mild fever", "diffuse rash", "body", "concerned", "health", "baby", "to", "medications", "make", "feel better", "short time", "Currently", "week", "gestation", "received", "tetanus vaccination", "part of", "antenatal care program", "received", "end", "first trimester", "Romania", "healthy", "Considering", "patient", "higher risk of giving birth", "newborn", "present", "following options"]}
{"question": "An investigator is studying bacterial adaptations to the environment in an infectious isolate and a noninfectious isolate of Hemophilus influenzae type B. Animals exposed to the noninfectious isolate do not develop symptoms of infection. The investigator cultivates the noninfectious isolate in a culture with lysed bacteria from the infectious isolate. Some of the animals exposed to these bacteria develop symptoms of infection. Which of the following processes is most likely responsible for the described findings?", "answer": "Transformation", "options": {"A": "Conjugation", "B": "Reassortment", "C": "Transformation", "D": "Recombination"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["investigator", "studying bacterial adaptations", "environment", "infectious isolate", "noninfectious isolate", "Hemophilus influenzae type B", "Animals exposed", "noninfectious isolate", "not", "symptoms", "infection", "investigator", "noninfectious isolate", "culture", "lysed bacteria", "infectious isolate", "animals exposed", "bacteria", "symptoms", "infection", "following processes", "most likely responsible", "described findings"]}
{"question": "A 40-year-old female with a past medical history of high cholesterol, high blood pressure, hyperthyroidism, and asthma presents to the primary care clinic today. She has tried several different statins, all of which have resulted in bothersome side effects. Her current medications include hydrochlorothiazide, levothyroxine, albuterol, oral contraceptives, and a multivitamin. Her physical examination is unremarkable. Her blood pressure is 116/82 mm Hg and her heart rate is 82/min. You decide to initiate colesevelam (Welchol). Of the following, which is a concern with the initiation of this medication?", "answer": "Timing of the dosing of colesevelam should be separated from this patient’s other medications.", "options": {"A": "Colesevelam can cause cognitive impairment.", "B": "Colesevelam can increase the risk of cholelithiasis.", "C": "Timing of the dosing of colesevelam should be separated from this patient’s other medications.", "D": "Colesevelam can significantly decrease your HDL."}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old female", "past medical history of high cholesterol", "high blood pressure", "hyperthyroidism", "asthma presents", "primary care clinic today", "different statins", "resulted", "side effects", "current medications include hydrochlorothiazide", "levothyroxine", "albuterol", "oral contraceptives", "multivitamin", "physical examination", "unremarkable", "blood pressure", "mm Hg", "heart rate", "min", "to initiate colesevelam", "Welchol", "following", "concern", "initiation", "medication"]}
{"question": "A 62-year-old patient with a history of deep venous thrombosis is enrolled in a clinical trial for a new oral anticoagulant. This novel drug has the property where its clearance is relatively predictable based on patient demographics and can easily be extrapolated from other data. Its metabolism and volume of distribution also do not change dramatically from patient to patient. The investigator wants to make sure that the plasma concentration of the drug in this patient is 15 mg/L and he knows the following drug characteristics.\n\nBioavailability: 50%\nDrug half-life: 2 hours\nVolume of distribution: 14.3 liters\n\nWhich of the following represents the maintenance dose that should be given to this patient every 8 hours?", "answer": "1200 milligrams", "options": {"A": "150 milligrams", "B": "430 milligrams", "C": "1200 milligrams", "D": "3600 milligrams"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["62 year old patient", "history of deep venous thrombosis", "enrolled", "clinical trial", "new oral anticoagulant", "novel drug", "property", "clearance", "predictable based", "patient demographics", "easily", "data", "metabolism", "volume of distribution", "not change", "patient", "patient", "investigator", "to make sure", "plasma concentration", "drug", "patient", "mg/L", "following drug characteristics", "Bioavailability", "50", "Drug half-life", "2 hours Volume of distribution", "liters", "following represents", "maintenance dose", "given", "patient", "8 hours"]}
{"question": "A 7-day-old infant boy presents to an emergency department due to poor feeding. His parents are recent immigrants to the United States. He was born in a traditional home birth and has never seen a medical provider. Mom had no prenatal care, has no medical issues, and is unvaccinated. The baby had been breastfeeding well until 24 hours ago when mom noticed he started having trouble latching. In the last 12 hours, he has completely refused to feed. He has had a decreased number of wet diapers and has stooled twice in the last 24 hours. His temperature is 98.6°F (37.0°C), pulse is 180/min, respirations are 52/min, and blood pressure is 70/50 mmHg. On exam, the infant has increased tone, a clenched jaw, no head lag, and clenched hands. Initial screening bloodwork is normal. What is the most likely organism causing this infant's presentation?", "answer": "Clostridium tetani", "options": {"A": "Clostridium botulinum", "B": "Clostridium tetani", "C": "Group B streptococcus", "D": "Listeria monocytogenes"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["day old infant boy presents", "emergency department", "poor feeding", "parents", "recent immigrants", "United States", "born", "traditional home birth", "never seen", "medical provider", "Mom", "prenatal care", "medical issues", "baby", "breastfeeding well", "24 hours", "mom", "started", "latching", "last 12 hours", "completely refused to feed", "decreased number", "wet diapers", "stooled twice", "24 hours", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "70 50 mmHg", "exam", "infant", "increased tone", "jaw", "head lag", "clenched hands", "Initial screening", "normal", "most likely organism causing", "infant's presentation"]}
{"question": "A 28-year-old woman presents with facial flushing, weakness, and chronic diarrhea for the past month. She denies any history of smoking, alcohol use, or recreational drug use. The patient was on a trip to Thailand 2 years ago with her family but denies any recent travel. Her blood pressure is 120/88 mm Hg, pulse is 78/min, temperature is 37.2°C (99.0°F), and respiratory rate is 16/min. Laboratory findings are unremarkable, except for a potassium level of 3.3 mmol/L and serum calcium of 11 mg/dL. The attending physician suspects that this might be a case of a genetic mutation in the menin 1 gene on chromosome 11 and orders a genetic analysis. Which of the following is the most likely diagnosis in this patient?", "answer": "VIPoma", "options": {"A": "Vibrio cholera infection", "B": "VIPoma", "C": "Rotavirus", "D": "Campylobacter jejuni"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "facial flushing", "weakness", "chronic diarrhea", "past month", "denies", "history of smoking", "alcohol use", "recreational drug use", "patient", "trip", "Thailand", "years", "family", "denies", "recent travel", "blood pressure", "88 mm Hg", "pulse", "min", "temperature", "99", "respiratory rate", "min", "Laboratory findings", "unremarkable", "except for", "potassium level", "3", "mmol/L", "serum calcium", "mg dL", "attending physician suspects", "case", "genetic mutation", "menin 1 gene", "chromosome 11", "orders", "genetic analysis", "following", "most likely diagnosis", "patient"]}
{"question": "A 69-year-old gentleman presents to his primary care physician for pain in his right shoulder. The patient was helping his son move this past weekend, and he noticed after the move that he had pain and weakness in his right shoulder. The patient thought that this pain was just him being in poor shape so he started going to the gym and lifting weights which made his symptoms significantly worse. The patient has a past medical history of diabetes, obesity, and asthma. His current medications include albuterol, lisinopril, metformin, and glipizide. On physical exam you note an obese gentleman who seems to be in pain. You note prominent weakness of external rotation of his right upper extremity. When you ask the patient to slowly lower his right arm to his side when he holds it overhead, you note that he suddenly drops his arm and appears to be in pain. The patient's strength is 1/5 for abduction of the right arm. Which of the following is most likely injured in this patient?", "answer": "Supraspinatus", "options": {"A": "Supraspinatus", "B": "Infraspinatus", "C": "Teres minor", "D": "Deltoid"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["69 year old", "presents", "primary care physician", "pain in", "right shoulder", "patient", "helping", "son move", "past weekend", "move", "pain", "weakness", "right", "patient thought", "pain", "poor shape", "started", "lifting weights", "made", "symptoms", "worse", "patient", "past medical diabetes", "obesity", "asthma", "current medications include albuterol", "lisinopril", "metformin", "glipizide", "physical exam", "note", "obese", "to", "pain", "note prominent weakness", "external rotation", "right upper extremity", "patient", "slowly lower", "right", "side", "holds", "note", "drops", "arm", "appears to", "pain", "patient's strength", "1/5", "abduction of", "right arm", "following", "most likely injured", "patient"]}
{"question": "A 9-year-old male visited his primary care physician for a check-up three months after a throat infection. Upon examination, the patient exhibits painless subcutaneous nodules on the back of the wrist, the outside elbow, and the front of the knees, as well as inflammation in the joints of the lower extremities. Which of the following symptoms is most likely to also be present in this patient?", "answer": "Chorea", "options": {"A": "Renal failure", "B": "Hepatomegaly", "C": "Chorea", "D": "Pleural effusion"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male visited", "primary care physician", "check-up three months", "throat infection", "examination", "patient exhibits painless subcutaneous nodules", "back of", "wrist", "outside elbow", "front", "knees", "inflammation", "joints of", "lower extremities", "following symptoms", "most likely", "present", "patient"]}
{"question": "A 29-year-old man diagnosed with schizophrenia 4 years ago presents for follow-up to discuss his medication. The patient was diagnosed with schizophrenia 4 years ago and has since tried several antipsychotic medications, none of which have been able to treat his negative symptoms. He has changed to clozapine 2 weeks ago and says that he does feel better. His physical exam is unremarkable, and he is responding appropriately to questioning. If this patient’s current medication is to be continued, which of the following laboratory tests should be ordered at this time?\n ", "answer": "Complete blood count", "options": {"A": "Slit-lamp examination", "B": "Electrocardiogram", "C": "Prolactin level", "D": "Complete blood count"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["29 year old man diagnosed", "schizophrenia 4 years", "presents", "follow-up", "discuss", "medication", "patient", "diagnosed", "schizophrenia 4 years", "since", "several antipsychotic medications", "able to treat", "negative symptoms", "changed", "clozapine 2 weeks", "feel better", "physical exam", "unremarkable", "questioning", "patients current medication", "to", "continued", "following laboratory tests", "ordered", "time"]}
{"question": "A 32-year-old man with HIV comes to the physician because of a 2-month history of weight loss, night sweats, and productive cough. Auscultation of the lungs shows coarse crackles at the right upper posterior field. An x-ray of the chest shows an opacity in the right upper lobe. Sputum analysis shows acid-fast bacilli. A small amount of tuberculin fluid is injected into the subcutaneous tissue on the left forearm. Examination of the injected area 48 hours later shows no induration or erythema. Impairment of which of the following processes is the most likely cause of the negative tuberculin skin test seen in this patient?", "answer": "Interaction of B7 and CD28 ligands", "options": {"A": "Interaction of B7 and CD28 ligands", "B": "Opsonization by complement proteins", "C": "Secretion of interleukin-4", "D": "Generation of reactive oxygen species"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "HIV", "physician", "of", "2 month history", "weight loss", "night sweats", "productive cough", "Auscultation", "lungs shows coarse crackles", "right posterior field", "x-ray of", "chest shows", "opacity", "right upper lobe", "Sputum analysis shows acid-fast bacilli", "small amount", "tuberculin fluid", "injected", "subcutaneous tissue", "left forearm", "Examination of", "injected area 48 hours later shows", "induration", "erythema", "Impairment", "following processes", "most likely cause", "negative tuberculin skin test seen", "patient"]}
{"question": "A 7-year-old boy is rushed to the emergency room after losing consciousness 30 mins ago at home. The patient’s mother says that he has had a “running nose” for the past few days However, he did not receive any treatment for it, and his condition rapidly worsened today. He does not have any significant past medical history. His vaccination records are up to date. His temperature is 38.2°C (100.7°F), blood pressure is 90/50 mm Hg, heart rate is 120/min, and respiratory rate is 22/min. On physical examination, the patient is unresponsive. There is a petechial rash present on his chest, and he has some neck rigidity. Empiric intravenous antibiotics are started, and a lumbar puncture is performed. Which of the following is the most likely cause of this patient’s low blood pressure?", "answer": "Adrenocortical insufficiency", "options": {"A": "Human immunodeficiency virus infection", "B": "Hypertrophic cardiomyopathy", "C": "Adrenocortical insufficiency", "D": "Pheochromocytoma"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "rushed", "emergency room", "consciousness 30 mins", "home", "patients mother", "running nose", "past", "days", "not receive", "treatment", "condition rapidly worsened today", "not", "significant past medical history", "vaccination records", "date", "temperature", "100", "blood pressure", "90 50 mm Hg", "heart rate", "min", "respiratory rate", "min", "physical examination", "patient", "unresponsive", "petechial rash present", "chest", "neck rigidity", "Empiric intravenous antibiotics", "started", "lumbar puncture", "performed", "following", "most likely cause", "patients low blood pressure"]}
{"question": "A chronic opioid abuser undergoes emergency surgery. Following the operation, the man is started on a patient controlled analgesia (PCA) thought to be dosed adequately to control his pain in the face of his opioid tolerance. He reports intense pain 6 hours after the conclusion of the surgery. Which agent could have been given intraoperatively to reduce this patient's risk of developing postoperative hyperalgesia?", "answer": "Ketamine", "options": {"A": "Ketamine", "B": "Midazolam", "C": "Propofol", "D": "Etomidate"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["chronic opioid", "emergency surgery", "Following", "operation", "man", "started", "patient controlled analgesia", "thought to", "dosed", "to control", "pain", "face", "opioid tolerance", "reports intense pain", "hours", "conclusion", "surgery", "agent", "given", "to", "patient's risk", "postoperative hyperalgesia"]}
{"question": "A 3550-g (7.8-lb) male newborn is delivered at term to a 27-year-old, gravida 1, para 1 woman (Rh+). Within the first 24 hours after birth, the newborn develops fever and a yellow discoloration of skin and sclerae. Examination shows loss of flexion in the extremities, splenomegaly, and cyanosis. Laboratory studies show decreased haptoglobin levels and increased LDH levels. A photomicrograph of a peripheral blood smear is shown. Which of the following is most likely involved in the pathogenesis of this patient's condition?", "answer": "Deficiency of ATP", "options": {"A": "Decrease in the reduced form of glutathione", "B": "Maternal antibodies against the rhesus D antigen", "C": "Deficiency of ATP", "D": "Osmotically fragile erythrocytes"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["male newborn", "delivered", "term", "27 year old", "gravida 1", "para 1 woman", "Rh", "first 24 hours after birth", "newborn", "fever", "yellow discoloration", "skin", "sclerae", "Examination shows loss", "flexion", "extremities", "splenomegaly", "cyanosis", "Laboratory studies show decreased haptoglobin levels", "increased LDH levels", "photomicrograph", "peripheral blood smear", "shown", "following", "most likely involved", "pathogenesis", "patient's condition"]}
{"question": "A 37-year-old woman presents to the emergency department with confusion, anxiety, sweating, and episodes of vomiting. She is accompanied by her sister who says that her symptoms developed acutely and is unsure about what caused it. She is currently on methimazole, which she last took approximately 1 week ago. Approximately 5 days ago she developed an upper respiratory infection managed with bed rest and ibuprofen. Her temperature is 105°F (40.6°C), blood pressure is 95/68 mmHg, pulse is 145/min, and respirations are 23/min. On physical examination, the patient has altered mentation and is agitated and diaphoretic. The patient also has a goiter, exophthalmos, warm skin, and a hand tremor. She is started on intravenous fluids. Which of the following is the best treatment option for this patient?", "answer": "Propranolol", "options": {"A": "Antibiotics", "B": "Carotid massage", "C": "Clonazepam", "D": "Propranolol"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "confusion", "anxiety", "sweating", "episodes of vomiting", "sister", "symptoms", "unsure", "caused", "currently", "methimazole", "last took approximately", "week", "days", "upper respiratory infection managed", "bed rest", "ibuprofen", "temperature", "40", "blood pressure", "95 68 mmHg", "pulse", "min", "respirations", "23 min", "physical examination", "patient", "altered", "agitated", "diaphoretic", "patient", "goiter", "exophthalmos", "warm skin", "hand tremor", "started", "intravenous fluids", "following", "best treatment", "patient"]}
{"question": "A 13-year-old boy is brought to the emergency department because he was vomiting and seemed abnormally sleepy at home. On presentation, he is found to be confused and very lethargic. His parents said that he has had a fever and cough for several days prior to presentation and was given an over the counter medication. Physical exam of this patient reveals mild hepatomegaly and dry mucous membranes. Which of the following effects would the drug most likely also have on the nephron?", "answer": "Constriction of afferent arteriole and no effect on efferent arteriole", "options": {"A": "Constriction of afferent arteriole and no effect on efferent arteriole", "B": "Dilation of afferent arteriole and no effect on efferent arteriole", "C": "No effect on afferent arteriole and constriction of efferent arteriole", "D": "No effect on afferent arteriole and dilation of efferent arteriole"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "vomiting", "sleepy", "home", "presentation", "found to", "confused", "very lethargic", "parents", "fever", "cough", "days", "presentation", "given", "over the counter medication", "Physical", "patient reveals mild hepatomegaly", "dry mucous membranes", "following effects", "drug", "likely", "nephron"]}
{"question": "A 54-year-old woman presents with sudden onset, mild vaginal bleeding for the past day. She says she is postmenopausal, and her last menstrual period was 5 years ago. A detailed workup is performed, and several premalignant lesions are found in her uterus. The patient agrees to a hysterectomy. The surgical team decides to use an anesthesia protocol consisting of nitrous oxide, desflurane, and atracurium. Which of the following best describes the role of atracurium in this patient’s anesthesia?", "answer": "It competes with acetylcholine for binding sites in the neuromuscular junction", "options": {"A": "It reduces neuron and muscle tissue excitability", "B": "It increases GABA linked chloride channel opening", "C": "It acts on the pain centers in the spinal cord and brain", "D": "It competes with acetylcholine for binding sites in the neuromuscular junction"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["54 year old woman presents", "sudden onset", "mild vaginal", "past day", "postmenopausal", "last menstrual period", "5 years", "detailed workup", "performed", "several premalignant lesions", "found", "uterus", "patient agrees", "hysterectomy", "surgical team", "to use", "anesthesia protocol consisting of nitrous oxide", "desflurane", "atracurium", "following best", "role", "atracurium", "patients anesthesia"]}
{"question": "A 22-year-old woman presents with recurrent episodes of swelling in her face, hands, and neck with occasional abdominal pain. The symptoms usually resolve in 2 to 3 days. She has had these swelling events her whole life; however, they have become more debilitating recently. Last week she had an event that restricted her ability to eat and swallow.  Past medical history is noncontributory. Her father is alive and well with no significant medical history. Her mother and her maternal aunt have a similar condition. Today, her physical exam is within normal limits. She brought a picture of her swollen hand as seen in the picture. The treating physician has a strong suspicion of an inherited disorder. C1-inhibitor levels are ordered and found to be extremely low. Which of the following is the most likely diagnosis of this patient?", "answer": "Hereditary angioedema", "options": {"A": "Chediak-Higashi syndrome", "B": "Wiskott-Aldrich syndrome", "C": "Paroxysmal nocturnal hemoglobinuria", "D": "Hereditary angioedema"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "recurrent episodes of swelling", "face", "hands", "neck", "occasional abdominal", "symptoms usually resolve", "3 days", "swelling events", "whole life", "more", "recently", "week", "event", "restricted", "ability", "eat", "swallow", "Past medical history", "father", "alive", "well", "significant medical history", "mother", "maternal aunt", "similar condition", "Today", "physical exam", "normal limits", "brought", "picture", "swollen hand", "seen", "picture", "treating physician", "strong suspicion", "inherited disorder", "C1-inhibitor levels", "ordered", "found to", "extremely low", "following", "most likely diagnosis", "patient"]}
{"question": "A 24-year-old woman gravida 2, para 1 at 24 weeks' gestation comes to the physician for a prenatal visit. She feels well. Her earlier pregnancy was uncomplicated. This is her 4th prenatal visit. She had an ultrasound scan 2 weeks ago that showed a live intrauterine pregnancy consistent with a 22-week gestation with no anomalies. She had a normal Pap smear 2 years ago. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 24-week gestation. Her blood group and type is B positive. Which of the following is the most appropriate next step in management?", "answer": "Oral glucose challenge test", "options": {"A": "Oral glucose challenge test", "B": "Cardiotocography", "C": "Swab for GBS culture", "D": "Tdap vaccination"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman gravida 2", "para 1", "weeks", "gestation", "physician", "prenatal visit", "feels well", "earlier pregnancy", "uncomplicated", "4th prenatal visit", "ultrasound scan", "weeks", "showed", "live intrauterine pregnancy consistent with", "week gestation", "anomalies", "normal Pap smear", "years", "Vital signs", "normal limits", "Pelvic examination shows", "uterus consistent", "size", "week gestation", "blood group", "type", "positive", "following", "most appropriate next step", "management"]}
{"question": "A 42-year-old man is brought to the emergency department because of a 2-day history of dyspnea, chest pain, and hemoptysis that were preceded by 4 days of myalgia and a low-grade fever. He is currently visiting the United States as a tourist from Turkey, where he works at a factory that processes sheep wool and hide. An x-ray of the chest shows widening of the mediastinum. A sputum culture grows gram-positive rods in gray colonies that have irregular margins with wavy projections on microscopy. Which of the following virulence factors of the causal organism increased its survival in host tissue?", "answer": "Glutamate capsule", "options": {"A": "Glutamate capsule", "B": "Toxin B", "C": "IgA protease", "D": "Sulfatides"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department", "2-day history", "dyspnea", "chest pain", "hemoptysis", "preceded", "4 days", "myalgia", "low-grade fever", "currently visiting", "United States", "tourist", "Turkey", "works", "factory", "processes sheep wool", "hide", "x-ray of", "chest shows widening", "mediastinum", "sputum culture", "gram-positive rods", "gray colonies", "irregular margins", "wavy projections", "microscopy", "following virulence factors", "causal organism increased", "survival", "host tissue"]}
{"question": "A 27-year-old woman, gravida 1, para 0, at 38 weeks' gestation is admitted to the hospital for active labor. The pregnancy was complicated by gestational diabetes and fetal weight is estimated to be at the 90th percentile for gestational age. During delivery, there is an arrest in the second stage of labor, and a vacuum-assisted delivery is performed. Postpartum examination shows a third-degree laceration in the vagina extending into the perineum at the 6 o'clock position. This patient is most likely to experience which of the following complications?", "answer": "Fecal incontinence", "options": {"A": "Urge incontinence", "B": "Vesicovaginal fistula", "C": "Fecal incontinence", "D": "Stress incontinence"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old woman", "gravida 1", "para 0", "weeks", "gestation", "admitted", "hospital", "active labor", "pregnancy", "complicated", "gestational diabetes", "fetal weight", "estimated to", "90th percentile", "gestational age", "delivery", "arrest", "second stage of labor", "vacuum assisted", "performed", "Postpartum examination shows", "third-degree laceration", "vagina extending", "perineum", "clock position", "patient", "most likely to experience", "following complications"]}
{"question": "A 63-year-old man presents to his primary care physician for follow-up. He reports a slow and steady weight gain of 6 pounds over the past 6 months, despite attempts to control his diet and increase his level of exercise. His medications include pravastatin, lisinopril, and hydrochlorothiazide. On exam, his vital signs are stable. He is obese (BMI 32), and his waist circumference is 43 inches. His physician is concerned about an abnormal fasting blood glucose and dyslipidemia. On further work-up with oral glucose tolerance test, the patient is diagnosed with diabetes. Which of the following associations is consistent with this patient’s most likely form of diabetes?", "answer": "Pancreatic islet cell amyloid deposition", "options": {"A": "Strong HLA class II gene makeup", "B": "Pancreatic islet cell amyloid deposition", "C": "Pancreatic islet cell leukocyte infiltration", "D": "Auto-antibodies against pancreatic islet cell antigens"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["63 year old man presents", "primary care physician", "follow-up", "reports", "slow", "steady weight gain", "pounds", "past 6 months", "attempts to control", "diet", "increase", "level", "exercise", "medications include pravastatin", "lisinopril", "hydrochlorothiazide", "exam", "vital signs", "stable", "obese", "BMI", "waist circumference", "inches", "physician", "concerned", "abnormal fasting blood glucose", "dyslipidemia", "further work-up", "oral glucose tolerance test", "patient", "diagnosed", "diabetes", "following associations", "consistent with", "patients", "likely form", "diabetes"]}
{"question": "A 45-year-old woman comes to the physician for the evaluation of a right breast mass that she noticed 3 weeks ago. It has rapidly increased in size during this period. She does not have pain. Vital signs are within normal limits. Examination shows large dense breasts; a 5-cm, nontender, multinodular mass is palpated in the right outer quadrant of the right breast. There are no changes in the skin or nipple. There is no palpable cervical or axillary adenopathy. Mammography shows a smooth polylobulated mass. Biopsy of the mass shows papillary projections of epithelial-lined stroma with hyperplasia and atypia. Which of the following is the most likely diagnosis?", "answer": "Phyllodes tumor", "options": {"A": "Phyllodes tumor", "B": "Fibroadenoma", "C": "Fibrocystic disease of the breast", "D": "Invasive lobular carcinoma"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "evaluation", "right breast mass", "3 weeks", "rapidly increased in size", "period", "not", "pain", "Vital signs", "normal limits", "Examination shows large dense breasts", "5", "nontender", "multinodular mass", "palpated", "right outer quadrant of", "breast", "changes in", "skin", "nipple", "palpable cervical", "axillary adenopathy", "Mammography shows", "smooth", "mass", "Biopsy", "shows papillary projections", "epithelial lined stroma", "hyperplasia", "atypia", "following", "most likely diagnosis"]}
{"question": "A 72-year-old Caucasian male presents to your office with dysphagia and halitosis. If this patient is also found to have cricopharyngeal muscle dysfunction, which of the following is the most likely cause of his presenting symptoms?", "answer": "Zenker's diverticulum", "options": {"A": "Gastroesophageal reflux disease", "B": "Esophageal candidiasis", "C": "Meckel's diverticulum", "D": "Zenker's diverticulum"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old Caucasian male presents", "office", "dysphagia", "halitosis", "patient", "found to", "muscle dysfunction", "following", "most likely cause", "presenting symptoms"]}
{"question": "A 10-year-old boy is brought to the emergency department because he has not been able to walk since waking up that morning. His mother said that when he tried to get out of bed that he was unable to stand without support. He also complained of prickling in his hands and feet. Three weeks ago, he had a fever, dry cough, and a sore throat. The fever and sore throat subsided a week after they began, but the cough is persisting. He has no history of serious illness and takes no medication. His vital signs are within normal limits. The lungs are clear to auscultation. There is severe weakness in both lower extremities and mild sensory loss of the hands and feet. Knee and ankle jerk reflexes are absent. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 12.0 g/dL\nLeukocyte count 6000/mm3\nSegmented neutrophils 64%\nEosinophils 2%\nLymphocytes 26%\nMonocytes 7%\nPlatelet count 160,000/mm3\nErythrocyte sedimentation rate 27 mm/h\nSerum\nNa+ 138 mEq/L\nCl- 101 mEq/L\nK+ 4.9 mEq/L\nHCO3- 26 mEq/L\nCa2+ 9.7 mg/dL\nCreatine kinase 93 U/L\nA lumbar puncture is performed; cerebrospinal fluid analysis shows a leukocyte count of 2/mm3, a glucose concentration of 60 mg/dL, and a protein concentration of 91 mg/dL. Which of the following is the most appropriate next step in treatment?\"", "answer": "Intravenous immunoglobulin (IVIG)", "options": {"A": "Intravenous immunoglobulin (IVIG)", "B": "Prednisone", "C": "Botulism antitoxin", "D": "Gabapentin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["A 10 year old boy", "brought", "emergency department", "not", "able to walk since waking up", "morning", "mother", "to get out", "bed", "unable to stand", "support", "prickling", "hands", "feet", "Three weeks", "fever", "dry cough", "sore throat", "fever", "sore throat", "week", "began", "cough", "history", "serious illness", "takes", "medication", "vital signs", "normal limits", "lungs", "clear", "auscultation", "severe weakness in", "lower extremities", "mild sensory loss of", "hands", "feet", "Knee", "ankle reflexes", "absent", "examination shows", "abnormalities", "Laboratory studies show", "Hemoglobin", "0", "count", "Segmented neutrophils 64", "Eosinophils 2", "Platelet count", "Erythrocyte sedimentation rate", "L", "U", "lumbar puncture", "performed", "cerebrospinal fluid analysis shows", "leukocyte count", "mm3", "glucose concentration", "60 mg/dL", "a protein concentration", "mg/dL", "following", "most appropriate next step", "treatment"]}
{"question": "A 27-year-old male presents to the psychiatrist requesting help with his compulsions as they are interfering with his life. He explains that he has this fear that something terrible will happen to his house if he does not check every appliance, outlet, window and door lock, faucet, and light fixture before he leaves. He states that he must check everything 7 times in a specific order and if he goes out of order he must start from the beginning and perform it all over. He has recently been fired from his job because he is always late and lost his fiancee as she could not deal with his habits anymore. The physician explained that cognitive-behavioral therapy may be of assistance and also prescribed clomipramine. Which of the following is the mechanism of reaction of clomipramine?", "answer": "Blocks reuptake of norepinephrine and serotonin", "options": {"A": "Decreases the degradation of norepinephrine and serotonin", "B": "Increases the release of norepinephrine and serotonin by alpha 2 receptor antagonism", "C": "Blocks only norepinephrine reuptake", "D": "Blocks reuptake of norepinephrine and serotonin"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["27 year old male presents", "psychiatrist requesting help", "compulsions", "interfering", "life", "fear", "terrible", "happen", "house", "not check", "appliance", "outlet", "window", "door lock", "light", "leaves", "states", "check", "times", "specific order", "goes out", "order", "start", "beginning", "perform", "all", "recently", "fired", "job", "always late", "lost", "not", "habits", "physician", "cognitive-behavioral therapy", "assistance", "prescribed clomipramine", "following", "mechanism", "reaction", "clomipramine"]}
{"question": "A 35-year-old Caucasian female presents to the hospital alarmed by her recent truncal weight gain, facial hair growth, and thinning skin. During the physical exam, the physician finds that the patient is hypertensive. Serum analysis reveals hyperglycemia. The physician suspects a pituitary adenoma. Which dexamethasone test result would help confirm the physician's suspicions?", "answer": "Low-dose, no change in ACTH; high-dose, decreased ACTH", "options": {"A": "Low-dose, increased ACTH; high-dose, decreased ACTH", "B": "Low-dose, decrease in ACTH; high-dose, no change in ACTH", "C": "Low-dose, no change in ACTH; high-dose, no change in ACTH", "D": "Low-dose, no change in ACTH; high-dose, decreased ACTH"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["35 year old Caucasian female presents", "hospital alarmed", "recent truncal weight gain", "facial", "thinning skin", "physical exam", "physician finds", "patient", "hypertensive", "Serum analysis reveals hyperglycemia", "physician suspects", "pituitary adenoma", "dexamethasone test result", "help confirm", "physician's suspicions"]}
{"question": "A 24-year-old man with chronic back pain comes to the physician to establish care after moving to Florida. He complains of anxiety, nausea, abdominal cramping, vomiting, and diarrhea for three days. He denies smoking, drinking alcohol, and using illicit drugs. He appears restless. His temperature is 37°C (98.6°F), pulse is 110/min, and blood pressure is 150/86 mm Hg. Physical examination shows dilated pupils, diaphoresis, and piloerection. His abdominal exam shows diffuse mild tenderness. There is no rebound tenderness or guarding. His hemoglobin concentration is 14.5 g/dL, leukocyte count is 8,000/mm, and platelet count is 250,000/mm3; serum studies and urinalysis show no abnormalities. Which of the following is the most appropriate pharmacotherapy?", "answer": "Methadone", "options": {"A": "Lorazepam", "B": "Naltrexone", "C": "Methadone", "D": "Naloxone\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "chronic back pain", "physician to establish care", "moving", "Florida", "anxiety", "nausea", "abdominal cramping", "vomiting", "diarrhea", "three days", "denies smoking", "drinking alcohol", "using illicit drugs", "appears restless", "temperature", "98", "pulse", "min", "blood pressure", "mm Hg", "Physical examination shows dilated pupils", "diaphoresis", "piloerection", "abdominal exam shows diffuse mild tenderness", "rebound tenderness", "guarding", "hemoglobin concentration", "g/dL", "leukocyte count", "mm", "platelet count", "mm3", "serum studies", "urinalysis show", "abnormalities", "following", "most appropriate pharmacotherapy"]}
{"question": "A 53-year-old man comes to the physician because of a 3-month history of cough and progressively worsening difficulty walking up the stairs in his apartment. He has noticed that it is easier for him to climb the stairs after he has exercised. He has also had a 4.6-kg (10.1-lb) weight loss over the past 6 months. He has smoked one pack of cigarettes daily for 35 years. Examination shows dry mucous membranes. The pupils are equal and react sluggishly to light. Muscle strength in the proximal lower extremity is initially 3/5 but increases to 5/5 after repeated muscle tapping. His achilles reflex is 1+. Which of the following is the most likely diagnosis?", "answer": "Lambert-Eaton syndrome", "options": {"A": "Polymyalgia rheumatica", "B": "Dermatomyositis", "C": "Hypothyroidism", "D": "Lambert-Eaton syndrome"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "3 month history", "cough", "worsening difficulty walking up", "stairs", "apartment", "easier", "to climb", "stairs", "exercised", "4.6 kg", "10", "weight loss", "past 6 months", "smoked one pack", "cigarettes daily", "35 years", "Examination shows dry mucous membranes", "pupils", "equal", "light", "Muscle strength", "proximal lower extremity", "initially", "increases", "repeated muscle", "achilles reflex", "1", "following", "most likely diagnosis"]}
{"question": "A 78-year-old woman presents to the emergency department with weight loss, abdominal pain, and jaundice. CT demonstrates a mass in the head of the pancreas, and biopsy is planned for the following day. The patient's daughter approaches you outside the room to request that the results of the biopsy not be shared with the patient. She asks that the results instead be shared with her and her brother, who is the patient's documented health care proxy. She explains that she and her brother have discussed the situation and decided that it is best to not inform the patient that she has cancer. Endoscopic ultrasound-guided biopsy the next morning confirms the diagnosis of pancreatic adenocarcinoma. Which of the following is the best response to the patient's daughter's request?", "answer": "Inquire why the patient's daughter feels her mother should not be informed of the diagnosis", "options": {"A": "Ask the patient's son, the documented health care proxy, how he would like to handle the situation", "B": "Inquire why the patient's daughter feels her mother should not be informed of the diagnosis", "C": "Offer to explain the diagnosis to the patient without using the word \"cancer\"", "D": "Tell the patient's daughter that the patient must be informed of the diagnosis"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "emergency department", "weight loss", "abdominal pain", "jaundice", "CT demonstrates", "mass", "the head of", "pancreas", "biopsy", "planned", "following day", "patient's daughter approaches", "outside", "room to request", "results", "biopsy not", "shared", "patient", "results", "shared", "brother", "patient's documented health care proxy", "brother", "discussed", "best", "not inform", "patient", "cancer", "Endoscopic ultrasound-guided biopsy", "next morning confirms the diagnosis of pancreatic adenocarcinoma", "following", "best response", "patient's daughter's request"]}
{"question": "A 59-year-old man presents to his primary care provider with fatigue. He has been seen in the emergency room 5 times in the past 2 years for acute alcohol intoxication. His past medical history is notable for diabetes mellitus and gout. He takes metformin, glyburide, and allopurinol. His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 86/min, and respirations are 16/min. He is in no acute distress. A positive fluid wave is noted. The dorsal surface of the tongue is depapillated, and there are erythematous swollen patches at the oral commissures. A complete blood count and iron studies are reported below:\n\nHemoglobin: 12.1 g/dL\nHematocrit: 36%\nLeukocyte count: 6,000/mm^3 with normal differential\nPlatelet count: 170,000/mm^3\n\nMean corpuscular volume: 70 um^3\nIron: 250 ug/dL\nFerritin: 300 ng/mL\nTotal iron binding capacity: 200 mcg/dL^3\n\nWhich of the following findings is most likely to be seen in this patient?", "answer": "Erythroblasts with mitochondrial iron deposits", "options": {"A": "Erythroblasts with mitochondrial iron deposits", "B": "Erythrocytes lacking central pallor", "C": "Erythrocytes with a ring of relative pallor", "D": "Inclusions of denatured hemoglobin"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["59 year old man presents", "primary care provider", "fatigue", "seen", "emergency room", "times", "past", "years", "acute alcohol intoxication", "past medical history", "notable", "diabetes mellitus", "gout", "takes metformin", "glyburide", "allopurinol", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "min", "respirations", "min", "acute distress", "positive fluid wave", "noted", "dorsal surface of", "tongue", "erythematous swollen patches", "oral commissures", "complete blood count", "iron studies", "reported", "Hemoglobin", "g/dL Hematocrit", "36", "Leukocyte count", "6", "mm 3", "normal differential Platelet count", "mm", "Mean corpuscular volume", "70", "Iron", "ug/dL Ferritin", "300 ng/mL Total iron binding capacity", "200 mcg/dL", "following findings", "most likely to", "seen", "patient"]}
{"question": "A 75-year-old man becomes pulseless in the cardiac intensive care unit 48 hours after admission for ST-elevation myocardial infarction. His blood pressure is 50/20 mm Hg. The ECG monitor shows a tachycardic irregular rhythm with erratic undulations, but no discernible P waves or QRS complexes. During immediate advanced cardiac life support, two attempts at defibrillation are made, after which the patient is given 1 mg of IV epinephrine. After another attempt at defibrillation, the patient remains pulseless and his blood pressure is 60/35 mm Hg. The ECG monitor shows no changes. Administration of which of the following is the most appropriate next step in management?", "answer": "Amiodarone", "options": {"A": "Amiodarone", "B": "Epinephrine", "C": "Dopamine", "D": "Atropine"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["75 year old man", "pulseless", "cardiac intensive care unit 48 hours", "admission", "ST-elevation myocardial infarction", "blood pressure", "50 20 mm Hg", "ECG monitor shows", "tachycardic irregular rhythm", "discernible P waves", "QRS complexes", "immediate advanced cardiac life support", "two attempts", "defibrillation", "made", "patient", "given 1 mg", "IV epinephrine", "attempt", "defibrillation", "patient", "pulseless", "blood pressure", "60 35 mm Hg", "ECG monitor shows", "changes", "Administration", "following", "most appropriate next step", "management"]}
{"question": "A 65-year-old man presents with left-sided numbness, diplopia, and blurring of vision. The diplopia is more prominent on his left-side lateral gaze. He denies having fever, headache, ocular pain, lacrimation, changes in color vision, or limb weakness. He has a past medical history of type-2 diabetes mellitus, hypertension, hypercholesterolemia, and ischemic heart disease. In addition, he had an ischemic stroke 9 years ago, from which he recovered completely with physiotherapy and rehabilitation. He has a history of a 56-pack-year cigarette smoking habit. His medications include aspirin, atorvastatin, glimepiride, metformin, metoprolol, and ramipril. The mental status examination is unremarkable. His muscle strength is normal in all 4 limbs. His sensations are decreased on his left side, including his face. The examination of extraocular movements is shown in the image. A lesion in which of the following locations explains the findings during eye examination?", "answer": "Medial longitudinal fasciculus", "options": {"A": "Cavernous sinus", "B": "Corticospinal tract before pyramidal decussation", "C": "Frontal eye field", "D": "Medial longitudinal fasciculus"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man presents", "left-sided numbness", "diplopia", "blurring of vision", "diplopia", "more prominent", "left lateral gaze", "denies", "fever", "headache", "ocular pain", "lacrimation", "changes", "color", "limb weakness", "past medical history of type-2 diabetes mellitus", "hypertension", "hypercholesterolemia", "ischemic heart disease", "addition", "ischemic stroke", "years", "recovered completely", "physiotherapy", "rehabilitation", "history of", "pack-year cigarette smoking habit", "medications include aspirin", "atorvastatin", "glimepiride", "metformin", "metoprolol", "ramipril", "mental", "unremarkable", "muscle strength", "normal", "limbs", "sensations", "decreased", "left side", "including", "face", "examination", "extraocular movements", "shown", "image", "lesion", "following locations", "findings", "eye"]}
{"question": "A 5-day-old boy is brought to the emergency department because of a 1-day history of poor feeding, irritability, and noisy breathing. The mother did not receive any prenatal care. His respirations are 26/min. Physical examination shows sunken fontanelles, tightly clenched fists, and erythema around the umbilical cord stump. Which of the following best describes the pathogenesis of the disease process in this patient?", "answer": "Decreased release of glycine", "options": {"A": "Inhibition of voltage-gated sodium channels", "B": "Destruction of Schwann cells", "C": "Decreased release of glycine", "D": "Destruction of anterior horn cells"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["5 day old boy", "brought", "emergency department", "1-day history", "poor feeding", "irritability", "noisy breathing", "mother", "not receive", "prenatal care", "respirations", "min", "Physical examination shows sunken fontanelles", "clenched fists", "erythema", "umbilical cord stump", "following best", "pathogenesis", "disease process", "patient"]}
{"question": "A 62-year-old woman comes to the physician because of a 6-month history of progressive pain and stiffness of the fingers of her right hand. The stiffness is worse at the end of the day. She recently retired after working for 28 years as a typist at a data entry firm. Physical examination shows swelling, joint-line tenderness, and decreased range of motion of the first metacarpophalangeal joint and the distal interphalangeal joints of the right hand. Discrete, hard, mildly tender nodules are palpated over the 2nd and 4th distal interphalangeal joints of the right hand. An x-ray of her right hand shows narrowing of the interphalangeal joint spaces with subchondral sclerosis and osteophytes. Which of the following is the most likely underlying mechanism of this patient's condition?", "answer": "Degenerative disease of the joints", "options": {"A": "Bacterial infection of the joint space", "B": "Autoimmune-mediated cartilage erosion", "C": "Calcium pyrophosphate dihydrate crystal precipitation in the joints", "D": "Degenerative disease of the joints"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "physician", "month history", "progressive pain", "stiffness of", "fingers", "right hand", "stiffness", "worse", "end", "day", "recently retired", "working", "years", "typist", "data entry firm", "Physical examination shows swelling", "joint line tenderness", "decreased range of motion", "first metacarpophalangeal joint", "the distal interphalangeal joints of", "right hand", "Discrete", "hard", "mildly tender nodules", "palpated", "2nd", "4th distal interphalangeal joints of the right hand", "x-ray", "right hand shows narrowing of the", "joint spaces", "sclerosis", "osteophytes", "following", "most likely underlying mechanism", "patient's condition"]}
{"question": "An 81-year-old man patient recently moved into an assisted living facility and presents today with itchy blisters in his axilla. He attributes these to a poor diet. He also complains that the nurse practitioner at the facility started him on 4 new medications, in addition to his existing prescriptions. On physical examination, tense axillary bullae are noted that do not rupture with light, gloved touch. On direct immunofluorescence, linear C3 and IgG deposits are seen along the basement membrane. Which of the following is the most likely diagnosis?", "answer": "Bullous pemphigoid", "options": {"A": "Staphylococcal scalded skin syndrome", "B": "Bullous pemphigoid", "C": "Pemphigus vulgaris", "D": "Cicatricial pemphigoid"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["81 year old man patient recently moved", "assisted living facility", "presents today", "itchy blisters", "axilla", "attributes", "poor diet", "nurse practitioner", "facility started", "4 new medications", "prescriptions", "physical examination", "tense axillary bullae", "noted", "not rupture", "light", "gloved touch", "direct immunofluorescence", "linear C3", "IgG deposits", "seen", "basement membrane", "following", "most likely diagnosis"]}
{"question": "A previously healthy 18-year-old army recruit is brought to a military treatment facility because of a 3-week history of right foot pain. He recently started basic infantry training and has been running several kilometers daily. Initially, the pain only occurred while running, but now it is also present at rest. The pain is located diffusely over the right forefoot. Vital signs are within normal range. Examination shows mild swelling over the distal right forefoot. Pressing the metatarsal of the third right toe results in pain. He walks with an antalgic gait. The remainder of the examination shows no abnormalities. An x-ray of the right foot shows a slight loss of cortical density and callus formation at the third metatarsal shaft. Which of the following is the most appropriate next step in management?", "answer": "Rest and acetaminophen", "options": {"A": "Rest and acetaminophen", "B": "Ultrasonography", "C": "Technetium bone scan", "D": "Internal fixation"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["healthy", "year old army", "brought", "military treatment facility", "3 week history", "right", "recently started basic", "training", "running several kilometers daily", "Initially", "pain only occurred", "running", "now", "present", "rest", "pain", "right forefoot", "Vital signs", "normal range", "Examination shows mild swelling", "distal right forefoot", "metatarsal", "third right toe results", "pain", "walks", "antalgic gait", "examination shows", "abnormalities", "x-ray of", "right foot shows", "slight loss", "cortical density", "callus formation", "third metatarsal shaft", "following", "most appropriate next step", "management"]}
{"question": "Thirty minutes after delivery, a 3600-g (7-lb 15-oz) newborn has noisy breathing, bluish discoloration of her lips, and intermittent respiratory distress. She was born at 38 weeks' gestation and required bag-mask resuscitation immediately after delivery. Pregnancy was uncomplicated. Her mother has noticed the bluish lip discoloration worsen when she fed and improve when she cried. The patient's pulse is 163/min, respirations are 62/min, and blood pressure is 60/30 mm Hg. The crying infant's lungs are clear to auscultation. Further evaluation of this patient is most likely to show which of the following?", "answer": "Passage of a catheter through the nasal cavity not possible", "options": {"A": "Diffuse reticulogranular densities on chest x-ray", "B": "Boot-shaped heart on chest x-ray", "C": "Passage of a gastric catheter through the mouth not possible", "D": "Passage of a catheter through the nasal cavity not possible"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["Thirty minutes", "delivery", "g", "oz", "newborn", "noisy breathing", "discoloration", "lips", "intermittent respiratory distress", "born", "weeks", "gestation", "required bag mask resuscitation immediately", "delivery", "Pregnancy", "uncomplicated", "mother", "lip discoloration worsen", "fed", "cried", "patient's pulse", "min", "respirations", "62 min", "blood pressure", "60 30 mm Hg", "crying infant's lungs", "clear", "auscultation", "Further evaluation", "patient", "most likely to show", "following"]}
{"question": "A 3-year-old girl is brought to the emergency department by her mother 30 minutes after the sudden onset of shortness of breath, dizziness, abdominal pain, and urticaria. The symptoms began 5 minutes after she ate a peanut butter sandwich. Her respirations are 36/min and blood pressure is 84/50 mm Hg. There is stridor on auscultation of the chest. She is intubated and mechanical ventilation is begun. Intravenous fluid resuscitation and the appropriate pharmacotherapy are begun. The drug administered to this patient most likely has which of the following effects on cardiac pacemaker cells during an action potential?", "answer": "Increased Ca2+ influx in phase 4", "options": {"A": "Increased Ca2+ influx in phase 4", "B": "Increased Na+ influx in phase 3", "C": "Decreased Ca2+ influx in phase 0", "D": "Decreased K+ efflux during phase 3\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old girl", "brought", "emergency department", "mother 30 minutes", "sudden onset of shortness", "breath", "dizziness", "abdominal pain", "urticaria", "symptoms began 5 minutes", "ate", "peanut butter sandwich", "respirations", "36 min", "blood pressure", "84 50 mm Hg", "stridor", "auscultation", "chest", "intubated", "mechanical ventilation", "begun", "Intravenous", "appropriate pharmacotherapy", "begun", "drug administered", "patient", "likely", "following effects", "cardiac pacemaker cells", "action potential"]}
{"question": "A 3-day-old boy is admitted to the neonatal intensive care unit for seizures. He was born to a 33-year-old woman at 31 weeks gestation via cesarean section. His birth weight was 1400 grams. Vital signs are significant for systemic hypotension, bradycardia, and hypoventilation. On physical exam, the patient has an altered level of consciousness with decreased spontaneous and elicited movements. The patient is hypotonic on motor testing, has bulging anterior fontanelle, and appears cyanotic. Which of the following is the best next step in management?", "answer": "Cranial ultrasonography", "options": {"A": "Complete blood count", "B": "Cranial ultrasonography", "C": "Head CT", "D": "MRI of the head"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["3 day old boy", "admitted to", "neonatal intensive care unit", "seizures", "born", "year old woman", "31 weeks gestation", "cesarean section", "birth weight", "grams", "Vital signs", "significant", "systemic hypotension", "bradycardia", "hypoventilation", "physical exam", "patient", "altered level of consciousness", "decreased spontaneous", "elicited movements", "patient", "hypotonic", "motor testing", "bulging anterior fontanelle", "appears cyanotic", "following", "best next step", "management"]}
{"question": "A 39-year-old man seeks an evaluation in the emergency room due to an episode of syncope at work. He says that he has felt increasing shortness of breath while exercising over the past 6 months. He is a well-built man in mild distress. The vital signs include heart rate 98/min, respiratory rate 18/min, temperature 36.5°C (97.7°F), and blood pressure 135/90 mm Hg. The cardiac examination is significant for a harsh systolic ejection murmur at the left lower sternal border which is accentuated by forceful expiration against a closed airway. Palpation of the carotid artery shows 2 closely spaced pulses which occur during systole. Which of the following is most consistent with these findings?", "answer": "Hypertrophic cardiomyopathy", "options": {"A": "Aortic stenosis", "B": "Cardiac tamponade", "C": "Hypertrophic cardiomyopathy", "D": "Third-degree heart block"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "evaluation", "emergency room due to", "episode of syncope", "work", "felt increasing shortness of breath", "exercising", "past 6 months", "well built man", "mild distress", "vital signs include heart rate 98 min", "respiratory rate", "min", "temperature 36", "97", "blood pressure", "90 mm Hg", "cardiac examination", "significant", "harsh systolic ejection murmur", "left lower sternal border", "accentuated", "forceful expiration", "closed airway", "Palpation", "carotid artery shows 2", "spaced pulses", "occur", "systole", "following", "most consistent with", "findings"]}
{"question": "A 26-year-old nullipara presents to her physician for a routine check-up at 18 weeks gestation. She has no co-morbidities. Her only complaints are fatigability and a depressed mood for the past 2 weeks. Her vital signs are as follows: blood pressure, 125/80 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The physical examination is unremarkable and the gynecologic examination is consistent with 18 weeks gestation. A thyroid profile s ordered to check for a possible cause of the fatigability and decreased mood:\nThyroid stimulating hormone (TSH) 0.3 mU/L\nTotal T4 160 nmol/L\nFree T4 13 pmol/L\nCorresponding to the obtained results, how should the patient be managed?", "answer": "No specific management required", "options": {"A": "Prescribe levothyroxine 50 mcg daily", "B": "No specific management required", "C": "Recommend additional anti-TPO test", "D": "Recommend additional T3 assessment"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old nullipara presents", "physician", "routine check-up", "weeks gestation", "co-morbidities", "only complaints", "fatigability", "depressed mood", "past 2 weeks", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate", "87 min", "respiratory rate", "min", "temperature", "36", "98", "physical examination", "unremarkable", "gynecologic examination", "consistent with", "weeks gestation", "thyroid profile", "ordered to check", "possible cause", "fatigability", "decreased mood", "Thyroid stimulating hormone", "0.3 mU/L Total T4", "nmol", "Free", "pmol", "obtained results", "patient", "managed"]}
{"question": "A 42-year-old man presents to your office complaining of right-sided facial swelling that has progressively worsened over the last month after returning from a trip to India. On examination, the patient has an obvious distortion of the facial features on the right without erythema or lymphadenopathy. A neurological exam reveals no deficits. His blood pressure is 115/80 mm Hg, heart rate is 65/min, and the temperature is 37.2°C (98.9°F). The patient states that he has been having trouble chewing his food, but is not experiencing any pain. The patient is up to date on all of his immunizations. Which of the following is the most likely cause of his facial swelling?", "answer": "Benign salivary gland tumor composed of stromal and epithelial tissue", "options": {"A": "Benign cystic tumor with stroma resembling lymph node tissue", "B": "Benign salivary gland tumor composed of stromal and epithelial tissue", "C": "An infection with paramyxovirus", "D": "Malignant tumor composed of squamous and mucinous cells"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "office", "right-sided facial swelling", "worsened", "month", "returning", "trip", "India", "examination", "patient", "distortion", "facial features", "right", "erythema", "lymphadenopathy", "neurological exam reveals", "deficits", "blood pressure", "80 mm Hg", "heart rate", "65 min", "temperature", "98 9F", "patient states", "chewing", "food", "not experiencing", "pain", "patient", "date", "of", "immunizations", "following", "most likely cause", "facial swelling"]}
{"question": "A 15-year-old boy is brought to the physician by his mother. His mother reports multiple instances over the past month when she walked into his room while he was masturbating. She is worried he may be going through some sort of “problem.” He is currently in 9th grade; his mother says that he is the captain of his high school wrestling team and does reasonably well in school. On examination, he seems embarrassed and avoids making eye contact. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Reassure the mother", "options": {"A": "Advise the patient to stop masturbating", "B": "Measure serum testosterone level", "C": "Reassure the mother", "D": "Prescribe sertraline"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "physician", "mother", "mother reports multiple instances", "past month", "walked", "room", "worried", "sort", "problem", "currently", "9th grade", "mother", "captain", "high school wrestling team", "well", "school", "examination", "embarrassed", "making eye contact", "Physical examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 64-year-old man presents to the clinic with easy fatigability and breathlessness when climbing stairs for the last 2 weeks. He also mentions that he occasionally has bouts of cough at night after about 2–3 hours of sleep which is relieved when he sits upright. He denies shortness of breath at rest, palpitations, and loss of consciousness. He has had hypertension for the last 20 years and is on antihypertensive medications. On physical examination, his temperature is 36.9°C (98.4°F), pulse is 104/min, blood pressure is 122/82 mm Hg, and respirations are 18/min. Chest auscultation reveals crackles over the lung bases bilaterally. Examination of his abdomen reveals mildly tender hepatomegaly. Laboratory investigation results include a hemoglobin of 14.8 g/dL (9.18 mmol/L) and an elevated serum B-type natriuretic peptide. His two-dimensional echocardiogram reveals an enlarged left atrium and an ejection fraction of 55%. Which of the following novel drugs is most likely to benefit the patient in addition to valsartan?", "answer": "Sacubitril", "options": {"A": "Etanercept", "B": "Moxonidine", "C": "Sacubitril", "D": "Aliskiren"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["64 year old man presents", "clinic", "easy fatigability", "breathlessness", "climbing stairs", "2 weeks", "occasionally", "bouts", "cough", "night", "about 23 hours of sleep", "relieved", "sits upright", "denies shortness of breath", "rest", "palpitations", "loss of consciousness", "hypertension", "20 years", "antihypertensive medications", "physical examination", "temperature", "36", "98 4F", "pulse", "min", "blood pressure", "mm Hg", "respirations", "min", "Chest auscultation reveals crackles", "lung bases", "Examination of", "abdomen reveals mildly tender hepatomegaly", "Laboratory investigation results include a hemoglobin", "8 g dL", "mmol/L", "elevated serum", "type natriuretic peptide", "two-dimensional echocardiogram reveals", "enlarged left atrium", "ejection fraction of 55", "following novel drugs", "most likely to benefit", "patient in addition to valsartan"]}
{"question": "A 69-year-old man presents to his primary care physician for trouble sleeping. The patient states that he recently retired from working the day shift at a cemetery. When the patient retired, his goal was to finally be able to go out with his wife; however, he finds that he is unable to stay awake past 6 pm in the evening. His inability to stay awake has been straining his marriage as his wife is disappointed that they cannot do any activities in the evening together. The patient has tried drinking caffeine but finds that it does not help. The patient’s wife claims that the patient seems to sleep peacefully, and the patient states he feels rested when he awakes. The patient has a past medical history of irritable bowel syndrome which is managed with fiber supplements. The patient’s neurological exam is within normal limits. Which of the following is the most likely diagnosis?", "answer": "Advanced sleep phase disorder", "options": {"A": "Obstructive sleep apnea", "B": "Advanced sleep phase disorder", "C": "Chronic insomnia", "D": "Normal aging"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["69 year old man presents", "primary care physician", "trouble sleeping", "patient states", "recently retired", "working", "day shift", "cemetery", "patient retired", "goal", "to", "able to go out", "wife", "finds", "unable to", "awake past", "pm in", "evening", "to", "awake", "straining", "marriage", "wife", "activities", "evening together", "patient", "drinking caffeine", "finds", "not help", "patients wife", "patient", "to sleep", "patient states", "feels rested", "awakes", "patient", "past medical history of irritable bowel syndrome", "managed", "fiber supplements", "patients neurological exam", "normal limits", "following", "most likely diagnosis"]}
{"question": "A 62-year-old woman comes to the physician for a routine health maintenance examination. She feels well. Six months ago, she was vaccinated against influenza. Her last mammography 1 year ago showed no abnormalities. Two years ago, a pap smear and colonoscopy were normal. She has a history of hypertension. Her father died of a myocardial infarction at the age of 50 years. She emigrated from Japan 30 years ago. She has smoked one-half pack of cigarettes daily for the last 18 years. She drinks 4–5 glasses of wine per day. She goes ballroom dancing twice each week. Her medications include enalapril and low-dose aspirin. She is 165 cm (5 ft 5 in) tall and weighs 50 kg (110 lb); BMI is 18 kg/m2. Vital signs are within normal limits. Cardiopulmonary examination shows a soft S4 gallop. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Dual-energy x-ray bone absorptiometry", "options": {"A": "Pap smear", "B": "Dual-energy x-ray bone absorptiometry", "C": "Abdominal ultrasonography", "D": "Transesophageal echocardiography"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["62 year old woman", "physician", "routine health maintenance examination", "feels well", "Six months", "vaccinated", "influenza", "last mammography", "year", "showed", "abnormalities", "Two years", "pap smear", "colonoscopy", "normal", "history of hypertension", "father died", "myocardial infarction", "age", "50 years", "Japan 30 years", "smoked one half pack", "cigarettes daily", "last", "years", "drinks", "glasses", "wine", "day", "goes", "dancing twice", "week", "medications include enalapril", "low-dose aspirin", "5 ft 5", "tall", "50 kg", "BMI", "kg/m2", "Vital signs", "normal limits", "Cardiopulmonary examination shows", "soft S4 gallop", "examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 25-year-old female with Hodgkin's lymphoma presents with a several day history of edema. Lab studies show:\n\nSerum Na+: 140 mmol/L\nSerum K+: 3.5 mmol/L\nSerum albumin: 1.9 g/dL\nTotal serum bilirubin: 1.0 mg/dL\nSerum creatinine: 1.2 mg/dL\n\nUrinalysis shows 4+ proteinuria and fatty casts. What is the most likely diagnosis?", "answer": "Minimal change disease", "options": {"A": "Focal segmental glomerulosclerosis", "B": "Membranous nephropathy", "C": "Minimal change disease", "D": "Amyloidosis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female", "Hodgkin's lymphoma presents", "day history", "edema", "Lab studies show", "Serum Na", "mmol/L Serum K", "3.5 mmol/L Serum albumin", "1.9 g/dL Total serum bilirubin", "1 0 mg dL Serum creatinine", "1.2 mg/dL", "Urinalysis shows 4", "proteinuria", "casts", "most likely diagnosis"]}
{"question": "A 45-year-old man comes to the physician because of mild left-sided abdominal pain when lifting heavy objects that has developed over the past 6 months. He has had a weight loss of 41 kgs (90 lbs) in the past year. Physical examination shows a soft bulge inferior and lateral to the navel on the left. A CT scan of the abdomen of a patient with the same condition is shown. Which of the following muscles is located directly medial to the pathology seen on the CT scan?", "answer": "Rectus abdominis", "options": {"A": "Psoas major", "B": "External oblique", "C": "Rectus abdominis", "D": "Transverse abdominal\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "mild left-sided abdominal pain", "lifting heavy objects", "past 6 months", "weight loss of", "90 lbs", "past year", "Physical examination shows", "soft bulge inferior", "lateral", "navel", "left", "CT scan", "abdomen", "patient", "same condition", "shown", "following muscles", "directly medial", "pathology seen", "CT scan"]}
{"question": "A 7-year-old woman presents shortly after her birthday with red scaly plaques over both ears. Her mother reports that the patient recently received a pair of fashionable silver earrings from her older sister as a birthday present. Physical examination is only significant for erythema and tenderness over the lobules of the ears bilaterally. Her vital signs show a blood pressure of 121/73 mm Hg, heart rate of 72/min, and a respiratory rate of 21/min. Her medical history is non-significant. Of the following options, which is the mechanism of this reaction?", "answer": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "options": {"A": "Type I–anaphylactic hypersensitivity reaction", "B": "Type III–immune complex-mediated hypersensitivity reaction", "C": "Type IV–cell-mediated (delayed) hypersensitivity reaction", "D": "Type III and IV–mixed immune complex and cell-mediated hypersensitivity reactions"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "red scaly plaques", "ears", "mother reports", "patient recently received", "pair", "silver", "older sister", "present", "Physical examination", "only significant", "erythema", "tenderness", "lobules", "ears", "vital signs show", "blood pressure", "mm Hg", "heart rate", "72 min", "respiratory rate", "min", "medical history", "non significant", "following options", "mechanism", "reaction"]}
{"question": "A 34-year-old man comes to the physician because of a 3-week history of colicky abdominal pain and diarrhea. He has bowel movements 10–12 times daily; the stool contains blood and mucus. He constantly has the urge to defecate. His vital signs are within normal limits. Examination of the abdomen shows diffuse tenderness to palpation. Serum concentration of C-reactive protein is 20 mg/L (N<10). Colonoscopy shows a bleeding, ulcerated rectal mucosa with several pseudopolyps. Which of the following is this patient at greatest risk of developing?", "answer": "Colorectal cancer", "options": {"A": "Hemolytic uremic syndrome", "B": "Oral ulcers", "C": "Colorectal cancer", "D": "Pancreatic cancer"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "3 week history", "colicky abdominal pain", "diarrhea", "bowel movements", "times daily", "stool contains blood", "mucus", "constantly", "vital signs", "normal limits", "Examination of", "abdomen shows diffuse tenderness", "palpation", "Serum concentration", "C-reactive protein", "20 mg/L", "N 10", "Colonoscopy shows", "bleeding", "ulcerated rectal mucosa", "pseudopolyps", "following", "patient", "greatest risk"]}
{"question": "A 32-year-old woman presents to the emergency department with complaints of a headache. The last menstrual period was 4 months ago. She also reports having a mild headache for 1 month. There has been a grape-like mass protruding from her vagina for the last 15 days. On examination, the fundus of the uterus is at the level of the umbilicus and no fetal heart sounds are heard. The vital signs are as follows: blood pressure 160/100 mm Hg, pulse rate 108/min. On USG examination, no fetal parts are seen. What will be the genotype of the substance which will be aspirated by dilation and evacuation?", "answer": "46XX", "options": {"A": "69XXY", "B": "23XX", "C": "47XYY", "D": "46XX"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "emergency department", "complaints", "headache", "last menstrual period", "4 months", "reports", "mild headache", "month", "grape", "mass protruding", "vagina", "last", "days", "examination", "fundus of", "uterus", "level", "umbilicus", "fetal heart sounds", "heard", "vital signs", "follows", "blood pressure", "100 mm Hg", "pulse rate", "min", "examination", "fetal parts", "seen", "genotype", "substance", "aspirated", "dilation", "evacuation"]}
{"question": "A 42-year-old woman comes to the clinic for a routine annual exam. She recently moved from New Jersey, and her medical records show a total colectomy. The patient reports that she has had annual colonoscopies since she was 10 years of age because her father had “a condition with his colon.” What is the genetic inheritance pattern of the patient’s disease?", "answer": "Autosomal dominant", "options": {"A": "Autosomal dominant", "B": "Autosomal recessive", "C": "Multifactorial", "D": "X-linked dominant"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "clinic", "routine annual exam", "recently moved from New Jersey", "medical records show", "total colectomy", "patient reports", "annual colonoscopies", "10", "age", "father", "condition", "colon", "genetic inheritance pattern of", "patients disease"]}
{"question": "A 2-day-old infant male is brought to the emergency department with a 5-hour history of vomiting and irritability. He was born at home and had unreliable prenatal care because his parents have been experiencing housing instability. About a day after birth, he started to become lethargic and was feeding poorly. His parents thought that he might just be tired so they put him to bed; however, by the next morning he started to vomit and act extremely irritable. On presentation, he is found to have nuchal rigidity and bulging fontanelles. Based on this presentation, appropriate cultures are obtained and he is placed on empiric antibiotics. After all cultures grow out the same gram-positive bacteria, the patient is narrowed to penicillin G. Which of the following is a characteristic of the most likely organism that is causing this patient's symptoms?", "answer": "Enlarges hemolytic area of Staphylococcus aureus", "options": {"A": "Enlarges hemolytic area of Staphylococcus aureus", "B": "Produces lipooligosaccharide rather than lipopolysaccharide", "C": "Produces toxin that increases cAMP levels", "D": "Tumbling motility in broth at 22 degrees"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["2-day old infant male", "brought", "emergency department", "5 hour history", "vomiting", "irritability", "born at home", "unreliable prenatal care", "parents", "experiencing housing instability", "day after birth", "started to", "lethargic", "feeding poorly", "parents thought", "tired", "put", "bed", "next morning", "started to vomit", "act extremely irritable", "presentation", "found to", "nuchal rigidity", "bulging fontanelles", "Based", "presentation", "appropriate cultures", "obtained", "placed", "empiric antibiotics", "cultures", "out", "same gram-positive bacteria", "patient", "narrowed", "penicillin G", "following", "characteristic", "likely organism", "causing", "patient's symptoms"]}
{"question": "A 58-year-old man with hypertension and dyslipidemia comes to the physician for a routine health maintenance examination. He says he feels well. He is 180 cm (5 ft 11 in) tall and weighs 103 kg (227 lb); BMI is 32 kg/m2. His BMI last year was 27 kg/m2. When asked about his diet, he says, “Being overweight runs in my family. Rather than fight it, I just try to enjoy myself and eat what I want.” Which of the following defense mechanisms best describes the patient's response to the physician?", "answer": "Rationalization", "options": {"A": "Rationalization", "B": "Fantasy", "C": "Distortion", "D": "Intellectualization"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["58 year old man", "hypertension", "dyslipidemia", "physician", "routine health maintenance examination", "feels well", "5 ft", "tall", "kg", "BMI", "kg/m2", "BMI", "year", "27 kg/m2", "diet", "overweight runs in", "family", "fight", "I", "to", "eat", "I", "following defense mechanisms best", "patient's response", "physician"]}
{"question": "A 27-year-old college student presents to his physician for constant fatigue. The patient states that for the past several weeks he has felt oddly fatigued and has struggled to complete his work. He is a foreign exchange student and is concerned he will fail out of his academic program. He has experienced some occasional nausea and vomiting which has caused him to lose weight. The patient is a first year college student, drinks alcohol regularly, smokes marijuana, and has unprotected sex with multiple partners. His temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Laboratory values are ordered as seen below.\n\nSerum:\nNa+: 139 mEq/L\nCl-: 100 mEq/L\nK+: 4.3 mEq/L\nHCO3-: 25 mEq/L\nBUN: 20 mg/dL\nGlucose: 99 mg/dL\nCreatinine: 1.1 mg/dL\nCa2+: 10.2 mg/dL\nTotal bilirubin: 2.0 mg/dL\nAST: 85 U/L\nALT: 92 U/L\n\nUrine\nColor: Amber/brown\nMarijuana: Positive\nAmphetamines: Positive\nCocaine: Positive\n\nThe patient refuses an examination of his genitals. Which of the following is the best diagnostic test?", "answer": "Viral core antibody", "options": {"A": "CAGE questions", "B": "Uretheral swab and culture", "C": "Viral core antibody", "D": "Viral surface antibody"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["27 year old college student presents", "physician", "constant fatigue", "patient states", "past", "weeks", "felt", "fatigued", "to complete", "work", "foreign exchange student", "concerned", "fail out", "academic program", "experienced", "occasional nausea", "vomiting", "caused", "to", "weight", "patient", "first year college student", "drinks alcohol", "smokes marijuana", "sex", "multiple partners", "temperature", "99", "blood pressure", "68 mmHg", "pulse", "90 min", "respirations", "min", "oxygen saturation", "98", "room air", "Laboratory values", "ordered", "seen", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "4", "mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "99 mg/dL Creatinine", "1.1 mg/dL Ca2", "10", "mg/dL Total bilirubin", "2 0 mg/dL AST", "85 U/L ALT", "U/L", "Urine Color", "Amber brown Marijuana", "Positive Amphetamines", "Positive Cocaine", "Positive", "patient refuses", "examination", "genitals", "following", "best diagnostic test"]}
{"question": "A 63-year-old woman comes to the physician because of a 6-month history of fatigue and shortness of breath on exertion in addition to a 1-month history of ankle swelling. She has a history of sleep apnea. Examination of the lower extremities shows bilateral pitting pedal and ankle edema. Cardiac examination shows a widely split S2 that varies with respiration. An ECG shows right bundle branch block. Which of the following is the most likely etiology of the patient's lower extremity edema?", "answer": "Increased capillary hydrostatic pressure", "options": {"A": "Localized lymphatic obstruction", "B": "Thrombus formation in a deep vein", "C": "Increased capillary hydrostatic pressure", "D": "Decreased plasma oncotic pressure\n\""}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["63 year old woman", "physician", "month history", "fatigue", "shortness of breath", "exertion in addition to", "month history", "ankle swelling", "history of sleep apnea", "Examination", "the lower extremities shows bilateral pitting pedal", "ankle edema", "Cardiac examination shows", "split S2", "varies", "respiration", "ECG shows right bundle branch block", "following", "most likely etiology of", "patient's lower extremity edema"]}
{"question": "A 62-year-old man presents with bright red blood in his stool which occurred 2 times this week. He denies fever, weight loss, pain, pruritus or urinary symptoms. Past medical history is significant for gastroesophageal reflux disease, and recent appendicitis, status post laparoscopic appendectomy complicated by delirium tremens. His vitals are a temperature of 37.0°C (98.6°F), blood pressure of 130/80 mm Hg, pulse of 78/min, and respiratory rate of 12/min. Physical examination reveals a distended abdomen with shifting dullness on percussion. In addition, multiple purple spider web-like lesions are present on the chest and arms, which blanch when pressure is applied. Fecal occult blood test is negative. On anoscopy, a non-tender, dilated vascular protrusion is noted superior to the pectinate line. Which of the following is most likely true about this patient’s current symptoms?", "answer": "The vascular protrusion drains into the superior rectal vein.", "options": {"A": "This patient has peptic ulcer disease.", "B": "The vascular protrusion drains into the superior rectal vein.", "C": "The vascular protrusion drains into the inferior rectal vein.", "D": "Fecal leukocytes and a stool culture are required for diagnosis."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["62 year old man presents", "bright red blood", "stool", "occurred 2 times", "week", "denies fever", "weight loss", "pain", "pruritus", "urinary symptoms", "Past medical history", "significant", "gastroesophageal reflux disease", "recent appendicitis", "laparoscopic appendectomy complicated", "delirium tremens", "temperature", "98", "blood pressure", "80 mm Hg", "pulse", "min", "respiratory rate", "min", "Physical examination reveals", "distended abdomen", "shifting dullness", "percussion", "addition", "multiple purple spider web", "lesions", "present", "chest", "arms", "blanch", "pressure", "applied", "Fecal occult blood test", "negative", "anoscopy", "non-tender", "dilated vascular protrusion", "noted superior", "pectinate line", "following", "most likely true", "patients current symptoms"]}
{"question": "A 55-year-old woman presents to the office because she has been feeling weak. For the past 2 years, she has been urinating a considerable volume every time she goes to the bathroom. She has no past medical history. Her heart rate is 86/min, respiratory rate is 15/min, temperature is 37.4°C (99.3°F), and blood pressure is 111/79 mm Hg. Laboratory studies are significant for the following:\nCalcium 13.8 mg/dL\nPTH 230 pg/mL\nHer complete metabolic panel is otherwise within normal limits. Imaging studies show subperiosteal resorption and osteoporosis. Scintigraphy reveals the most common pathologic condition associated with the patient’s diagnosis. Which of the following is the most likely diagnosis in this patient?", "answer": "Adenoma", "options": {"A": "Adenoma", "B": "Carcinoma", "C": "Decreased calcitriol concentration", "D": "Phosphate retention"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["55 year old woman presents", "office", "feeling weak", "past", "years", "volume", "time", "goes", "bathroom", "past medical history", "heart rate", "min", "respiratory rate", "min", "temperature", "4C", "99", "blood pressure", "mm Hg", "Laboratory studies", "significant", "following", "Calcium", "mg/dL", "pg/mL", "complete metabolic panel", "normal limits", "Imaging studies show subperiosteal resorption", "osteoporosis", "Scintigraphy reveals", "most common pathologic condition associated with", "patients diagnosis", "following", "most likely diagnosis", "patient"]}
{"question": "A 35-year-old woman presents to a psychiatrist for an initial consultation. She reports that for the past 3 years, she has experienced several periods of depressed mood. The episodes do not coincide with any specific life events and seem to resolve after 4-6 weeks. During these episodes, she experiences a depressed mood, sleep disturbances, and a poor appetite, but she at times is able to enjoy spending time with her children and husband but other times she is distressed and cannot enjoy time with them. Upon further questioning, she also reports experiencing occasional episodes of elevated mood over the past ten years. During these episodes, she is very productive at her work as a lawyer and requires less sleep than usual. Her past medical history is notable for obesity, type I diabetes mellitus, and rheumatoid arthritis. She is on insulin and takes methotrexate. She smokes marijuana occasionally. Her temperature is 99.2°F (37.3°C), blood pressure is 124/80 mmHg, pulse is 78/min, and respirations are 17/min. On exam, she is quiet with a flattened affect, but is cooperative and answers questions thoroughly. Which of the following is the most likely diagnosis in this patient?", "answer": "Cyclothymic disorder", "options": {"A": "Bipolar I disorder", "B": "Cyclothymic disorder", "C": "Persistent depressive disorder", "D": "Schizoaffective disorder"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old woman presents", "psychiatrist", "initial consultation", "reports", "past", "years", "periods", "depressed mood", "episodes", "not", "specific life events", "to resolve", "weeks", "episodes", "experiences", "depressed mood", "sleep disturbances", "poor appetite", "times", "able", "spending time", "children", "husband", "times", "distressed", "time", "further questioning", "reports experiencing occasional episodes of elevated mood", "past ten years", "episodes", "very productive at", "work", "lawyer", "less sleep", "usual", "past medical history", "notable", "obesity", "type I diabetes mellitus", "rheumatoid arthritis", "insulin", "takes methotrexate", "smokes marijuana occasionally", "temperature", "99", "3C", "blood pressure", "80 mmHg", "pulse", "min", "respirations", "min", "exam", "quiet", "flattened affect", "cooperative", "answers questions thoroughly", "following", "most likely diagnosis", "patient"]}
{"question": "A 76-year-old woman comes to the physician for a routine examination. She has a history of hypertension well controlled with diet and exercise. She has no history of smoking or illicit drug use. She walks one mile daily. Her pulse is 68/min, respirations are 16/min, and blood pressure is 119/76 mm Hg. Physical examination shows no abnormalities. When compared to a healthy 20-year-old woman, which of the following changes in respiratory function is most likely present in this patient?", "answer": "Increased lung compliance", "options": {"A": "Increased lung compliance", "B": "Decreased residual volume", "C": "Increased chest wall compliance", "D": "Decreased A-a gradient"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["76 year old woman", "physician", "routine examination", "history of hypertension well", "diet", "exercise", "history of smoking", "illicit drug use", "walks one mile daily", "pulse", "68 min", "respirations", "min", "blood pressure", "76 mm Hg", "Physical examination shows", "abnormalities", "compared", "healthy 20 year old woman", "following changes", "respiratory function", "most likely present", "patient"]}
{"question": "A 32-year-old man jumps off a 3 story building during a suicide attempt. Paramedics arrive quickly, and he is taken to the hospital where several stable lumbar fractures and a shattered right calcaneus are found. He undergoes surgery and his calcaneus is repaired with 11 screws. Which of the following statements best describes the long term post-surgery outcome in this patient?", "answer": "He will have pain with inversion and eversion of his foot.", "options": {"A": "He will not be able to plantar flex his foot.", "B": "He will not be able to point his toe.", "C": "He will have pain with inversion and eversion of his foot.", "D": "He will have pain while dorsiflexing his foot."}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man jumps", "3 story building", "suicide attempt", "Paramedics", "taken", "hospital", "stable lumbar", "right calcaneus", "found", "surgery", "calcaneus", "repaired", "screws", "following statements best", "long term post-surgery outcome", "patient"]}
{"question": "A 46-year-old man comes to the emergency department because of a 4-week history of fatigue and headache that have gotten progressively worse. He has allergic asthma treated with inhaled salbutamol. He immigrated to the USA from Thailand 9 years ago. He lives by himself and works as a waiter in a restaurant. He has had 6 lifetime male sexual partners and uses condoms inconsistently. He drinks 1–2 beers daily. His temperature is 38.2°C (100.8°F), pulse is 88/min, and blood pressure is 128/76 mm Hg. Examination of the mouth shows several white patches on the tongue and oral mucosa that can be easily scraped off with a tongue blade. On mental status examination, the patient is somnolent and has short-term memory deficits. The remainder of the examination shows no abnormalities. Laboratory studies show:\nHemoglobin 13.6 g/dL\nLeukocyte count 9,600/mm3\nSegmented neutrophils 80%\nEosinophils 1%\nLymphocytes 17%\nMonocytes 2%\nCD4+ T-lymphocytes 80/mm3 (Normal ≥ 500)\nPlatelet count 328,000/mm3\nSerum\npH 7.36\nNa+ 135 mEq/L\nCl- 101 mEq/L\nK+ 4.8 mEq/L\nHCO3- 22 mEq/L\nGlucose 95 mg/dL\nCreatinine 0.9 mg/dL\nBUN 16 mg/dL\nBilirubin, total 0.7 mg/dL\nAST 13 U/L\nALT 15 U/L\nErythrocyte sedimentation rate 10 mm/hour\nHIV test positive\nA lumbar puncture is performed and an opening pressure of 150 mm H2O is noted. Cerebrospinal fluid analysis shows a leukocyte count of 25/mm3 (60% lymphocytes), protein concentration of 52 mg/dL, and a glucose concentration of 37 mg/dL. India ink stain shows organisms with prominent capsules. Blood cultures are drawn. Which of the following is the most appropriate pharmacotherapy for this patient's neurological symptoms?\"", "answer": "Amphotericin B and flucytosine", "options": {"A": "Pyrimethamine, sulfadiazine, and folinic acid", "B": "Amphotericin B and flucytosine", "C": "Fluconazole", "D": "Vancomycin and meropenem"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "emergency department", "4 week history", "fatigue", "headache", "gotten", "worse", "allergic asthma treated with inhaled salbutamol", "USA", "Thailand", "years", "lives", "works", "waiter", "restaurant", "lifetime male sexual partners", "uses condoms", "drinks", "beers daily", "temperature", "100", "pulse", "88 min", "blood pressure", "76 mm Hg", "Examination of", "mouth shows several white patches", "tongue", "oral mucosa", "easily scraped", "tongue blade", "mental", "patient", "somnolent", "short-term memory deficits", "examination shows", "abnormalities", "Laboratory studies show", "Hemoglobin 13.6 g dL Leukocyte count", "600 mm3 Segmented neutrophils 80", "Eosinophils 1", "Lymphocytes", "Monocytes 2", "CD4", "T-lymphocytes", "Normal", "500", "Platelet count", "mm3 Serum pH 7", "mEq", "K", "4", "HCO3", "95 mg dL", "0", "16", "Bilirubin", "total 0.7 mg/dL AST", "U", "ALT", "Erythrocyte sedimentation rate 10 mm hour HIV test positive", "lumbar puncture", "performed", "opening pressure", "mm H2O", "noted", "Cerebrospinal fluid analysis shows", "leukocyte count", "mm3", "60", "lymphocytes", "protein concentration", "mg/dL", "glucose concentration", "mg/dL", "India ink stain shows organisms", "prominent capsules", "Blood cultures", "drawn", "following", "most appropriate pharmacotherapy", "patient", "eurological "]}
{"question": "A previously healthy 16-year-old boy comes to the physician because of a 5-day history of pain at the back of his left ankle. His mother had a myocardial infarction at 54 years. His BMI is 23 kg/m2. There is tenderness above the left posterior calcaneus and a firm, 3-cm, skin-colored nodule that moves with the left Achilles tendon. A photomicrograph from a biopsy of the nodule is shown. Serum studies in this patient are most likely to show increased levels of which of the following?", "answer": "Low-density lipoprotein", "options": {"A": "Rheumatoid factor", "B": "Angiotensin converting enzyme", "C": "Low-density lipoprotein", "D": "Triglycerides"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old boy", "physician", "5-day history", "pain", "back of", "left ankle", "mother", "myocardial infarction", "54 years", "BMI", "23 kg/m2", "tenderness", "left calcaneus", "firm", "3", "skin colored nodule", "moves", "left Achilles tendon", "photomicrograph", "biopsy", "nodule", "shown", "Serum studies", "patient", "most likely to show increased levels"]}
{"question": "A 3-year-old boy presents with episodic diarrhea with malodorous stools, stunted growth, occasional abdominal cramps, and an itchy rash. His mother says that these symptoms developed approximately 2 years ago. The patient was exclusively breastfed up to the age of 7 months. Supplementary feeding was started with non-starchy vegetable followed by starchy vegetables, meat, fish, eggs, and bread. Bread and cookies were the last product to be introduced at the age of 12 months. The patient’s mother tried to withdraw dairy products from the patient’s diet because she heard that lactose can cause such symptoms, but it did not help. The patient’s vital signs include: blood pressure 90/55 mm Hg, heart rate 101/min, respiratory rate 19/min, and temperature 36.3℃ (97.3℉). His weight is 11 kg (24.2 lb, -2 SD) and height is 90 cm (2 ft 11 in, -1 SD). On physical examination, the patient’s skin is pale with a papulovesicular rash on his abdomen and back. There are a few aphthous ulcers in the oral cavity. The abdomen is distended but no tenderness to palpation. No hepatosplenomegaly. An immunological assay is performed and shows positive anti-transglutaminase and anti-endomysial antibodies. Which of the following changes would you most likely expect to see on intestinal biopsy in this patient?", "answer": "Villous atrophy and crypt hypertrophy", "options": {"A": "Granulomas in the submucous tissue", "B": "Crypt abscesses", "C": "Villous atrophy and crypt hypertrophy", "D": "Villous hyperplasia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["3 year old boy presents", "episodic diarrhea", "stools", "growth", "occasional abdominal cramps", "itchy rash", "mother", "symptoms", "approximately", "years", "patient", "breastfed", "age", "months", "Supplementary feeding", "started", "non starchy vegetable followed by starchy vegetables", "meat", "fish", "eggs", "bread", "Bread", "cookies", "last product to", "introduced", "age", "months", "patients mother", "to withdraw dairy products", "patients diet", "heard", "lactose", "cause", "symptoms", "not help", "patients vital signs include", "blood pressure 90 55 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "97", "weight", "kg", "2 SD", "height", "90", "2 ft", "1 SD", "physical examination", "patients skin", "pale", "papulovesicular rash", "abdomen", "back", "few aphthous ulcers", "oral cavity", "abdomen", "distended", "tenderness", "palpation", "hepatosplenomegaly", "immunological assay", "performed", "shows positive", "transglutaminase", "anti-endomysial antibodies", "following changes", "most likely", "to see", "intestinal biopsy", "patient"]}
{"question": "An 18-year-old patient is visiting the pediatrician with her mother for her annual exam before college starts. Her height and weight are appropriate for her age, and she is up to date on all her vaccinations and has no medical complaints. She is doing well in school and has a part-time job stocking shelves at a clothing store. She was offered a higher-paying job as a cashier at the store, but she declined. She is very shy and withdrawn with the physician. Afterwards, her mother asks to speak to the physician alone and expresses concern that her daughter is very socially isolated and feels lonely. She is also worried that her daughter is extremely sensitive to criticism, even from family. The daughter is interested in art and music, but hasn’t participated in any extracurriculars because she says that she is untalented and thinks nobody wants to hang out with her. When her mother has encouraged her to invite friends over, the daughter bursts into tears and says, “Nobody wants to be friends with me, I am too lame and ugly and I just know I’ll end up getting rejected.” Which of the following is the most likely explanation for the daughter’s behavior?", "answer": "Avoidant personality disorder", "options": {"A": "Schizotypal personality disorder", "B": "Generalized anxiety disorder", "C": "Avoidant personality disorder", "D": "Dependent personality disorder"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old patient", "visiting", "pediatrician", "mother", "annual exam", "college starts", "height", "weight", "appropriate", "age", "date", "vaccinations", "medical complaints", "well", "school", "part-time job stocking shelves", "clothing store", "offered", "higher paying job", "store", "very shy", "withdrawn", "physician", "mother", "speak", "physician alone", "concern", "daughter", "very", "isolated", "feels lonely", "worried", "daughter", "extremely sensitive to criticism", "family", "daughter", "interested", "art", "music", "hasnt", "thinks", "hang out", "mother", "friends", "daughter bursts", "tears", "to", "friends", "I", "I", "Ill end", "getting rejected", "following", "most likely explanation", "daughters behavior"]}
{"question": "A 15-year-old girl comes to the physician because of a 2-week history of genital lesions. She has no history of serious illness. She is sexually active with 2 male partners and uses condoms inconsistently. Vital signs are within normal limits. Pelvic examination shows multiple hyperkeratotic exophytic papules over the vulva. The lesions turn white on application of 3% acetic acid. Which of the following is most likely to have prevented this patient's condition?", "answer": "Vaccination", "options": {"A": "Condoms", "B": "Anti-HIV prophylaxis", "C": "Spermicidal foam", "D": "Vaccination"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old girl", "physician", "of", "2-week history", "genital lesions", "history", "serious illness", "sexually active", "male partners", "uses condoms", "Vital signs", "normal limits", "Pelvic examination shows multiple hyperkeratotic exophytic papules", "vulva", "lesions turn white", "application", "acetic acid", "following", "most likely to", "prevented", "patient's condition"]}
{"question": "A 48-year-old woman comes to the emergency department because of a 1-day history of fever, vomiting, and abdominal pain. Two weeks ago, while visiting Guatemala, she had an emergency appendectomy under general inhalational anesthesia. During the surgery, she received a transfusion of 1 unit of packed red blood cells. Her temperature is 38.3°C (100.9°F) and blood pressure is 138/76 mm Hg. Examination shows jaundice and tender hepatomegaly. Serum studies show:\nAlkaline phosphatase 102 U/L\nAspartate aminotransferase 760 U/L\nBilirubin\nTotal 3.8 mg/dL\nDirect 3.1 mg/dL\nAnti-HAV IgG positive\nAnti-HAV IgM negative\nAnti-HBs positive\nHBsAg negative\nAnti-HCV antibodies negative\nAbdominal ultrasonography shows an enlarged liver. A biopsy of the liver shows massive centrilobular necrosis. Which of the following is the most likely underlying cause of this patient's condition?\"", "answer": "Adverse effect of anesthetic", "options": {"A": "Acalculous inflammation of the gallbladder", "B": "Virus-mediated hepatocellular injury", "C": "Adverse effect of anesthetic", "D": "Gram-negative bacteria in the bloodstream"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["48 year old woman", "emergency department", "1-day history", "fever", "vomiting", "abdominal pain", "Two weeks", "visiting Guatemala", "emergency appendectomy", "general inhalational anesthesia", "surgery", "received", "transfusion of", "packed red blood cells", "temperature", "3C", "100 9F", "blood pressure", "76 mm Hg", "Examination shows jaundice", "tender hepatomegaly", "Serum studies show", "Alkaline phosphatase", "U/L Aspartate aminotransferase", "Bilirubin Total", "mg/dL Direct 3.1 mg/dL Anti IgG positive", "IgM negative", "HBs", "HBsAg", "HCV antibodies", "Abdominal ultrasonography shows", "enlarged liver", "biopsy of", "liver shows massive centrilobular necrosis", "following", "most likely underlying cause", "patient", "ondition?"]}
{"question": "A 10-year-old African American girl with known sickle cell disease becomes acutely anemic in the setting of underlying infection. Her mother denies any previous history of blood clots in her past, but she says that her mother has also had to be treated for pulmonary embolism in the recent past. The patient’s past medical history is significant for a few episodes of acute pain crisis and a need for splenectomy 3 years ago. The vital signs upon arrival include: temperature 36.7°C (98.0°F), blood pressure 106/74 mm Hg, heart rate 111/min and regular, and respiratory rate 17/min. On physical examination, her pulses are bounding and fingernails are pale, but breath sounds remain clear. Oxygen saturation was initially 91% on room air and electrocardiogram (ECG) shows sinus tachycardia. A blood transfusion is initiated. Shortly after the transfusion has begun, the patient experiences fevers, chills, a burning sensation at the intravenous (IV) site, and sudden hypotension. What is the name of this reaction, and what is the best treatment?", "answer": "Hemolytic transfusion reaction; discontinue transfusion", "options": {"A": "Nonhemolytic febrile reaction; administer antihistamines", "B": "Minor allergic reaction; discontinue transfusion", "C": "Hemolytic transfusion reaction; administer antihistamines", "D": "Hemolytic transfusion reaction; discontinue transfusion"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["A 10 year old African American girl", "known sickle cell disease", "anemic", "setting", "underlying infection", "mother denies", "previous history", "blood clots", "past", "mother", "to", "treated", "pulmonary embolism", "recent past", "patients past medical history", "significant", "episodes of acute", "need", "splenectomy", "years", "vital signs", "arrival include", "temperature 36", "98", "blood pressure", "74 mm Hg", "heart rate", "min", "regular", "respiratory rate", "min", "physical examination", "pulses", "bounding", "fingernails", "pale", "breath sounds", "clear", "Oxygen saturation", "initially", "room air", "electrocardiogram", "shows sinus tachycardia", "blood transfusion", "initiated", "transfusion", "begun", "patient experiences fevers", "chills", "burning sensation", "intravenous", "site", "sudden hypotension", "name", "reaction", "best treatment"]}
{"question": "A 46-year-old woman comes to the physician because of severe muscle and joint pain for 5 months. The pain varies in location and intensity. She also has joint stiffness in the morning and reports fatigue throughout the day that she attributes to not sleeping well. She reports a tingling sensation in her lower limbs. Her bowel habits are unchanged but she often feels bloated. She has primary hypertension and occasional migraine headaches. She does not smoke or consume alcohol. Her medications include propranolol and sumatriptan. She appears healthy. Examination shows symmetric muscular tenderness at the base of the neck, over the shoulders, and in the lumbosacral area. Strength and deep tendon reflexes are normal. Laboratory studies show:\nHemoglobin 14.3 g/dL\nLeukocyte count 9300/mm3\nPlatelet count 230,000/mm3\nMean corpuscular volume 85 μm3\nErythrocyte sedimentation rate 12 mm/h\nSerum\nGlucose 92 mg/dL\nCreatinine 0.6 mg/dL\nTSH 3.1 μU/mL\nUrinalysis is within normal limits. Which of the following is the most appropriate therapy for this patient?\"", "answer": "Amitriptyline", "options": {"A": "Temazepam", "B": "Vitamin B12", "C": "Amitriptyline", "D": "Methotrexate\n\""}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "severe muscle", "joint pain", "months", "pain varies", "location", "intensity", "joint stiffness", "morning", "reports fatigue", "day", "attributes to not sleeping well", "reports", "tingling sensation", "lower limbs", "bowel habits", "unchanged", "often feels bloated", "primary hypertension", "occasional migraine headaches", "not smoke", "alcohol", "medications include propranolol", "sumatriptan", "appears healthy", "Examination shows symmetric muscular", "base", "neck", "shoulders", "lumbosacral area", "Strength", "deep tendon reflexes", "normal", "Laboratory studies show", "Hemoglobin", "g", "Leukocyte", "Platelet", "Mean", "m3 Erythrocyte sedimentation rate 12", "h", "mg", "mg", "Urinalysis", "normal limits", "following", "most appropriate therapy", "patient"]}
{"question": "A 68-year-old man presents with difficulty breathing for the last 3 hours. Upon asking about other symptoms, he mentions that he had a cough for the last 4 months which he attributes to his smoking. He says he had frequent nasal stuffiness and headaches over the last 3 months, for which he takes over-the-counter cold medications and analgesics. Over the last 2 months, he often felt that his face was mildly swollen, especially in the morning hours, but he did not consider it to be anything serious. No significant past medical history. He reports a 20-pack-year smoking history. His temperature is 36.8°C (98.4°F), pulse is 96/min, blood pressure is 108/78 mm Hg, and the respiratory rate is 24/min. On physical examination, auscultation of the chest reveals rhonchi and crepitus over the right lung. The remainder of the exam is unremarkable. A chest radiograph reveals a mass in the middle lobe of the right lung. Which of the following clinical signs would most likely be present in this patient?", "answer": "Papilledema", "options": {"A": "Bilateral pedal edema", "B": "Distended veins over lower abdomen", "C": "Papilledema", "D": "Sensory loss over the ulnar aspect of right forearm and right hand"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["68 year old man presents", "difficulty breathing", "last", "hours", "symptoms", "cough", "months", "attributes", "smoking", "frequent nasal stuffiness", "headaches", "months", "takes over-the-counter cold medications", "analgesics", "last", "months", "often felt", "face", "mildly swollen", "morning hours", "not consider", "to", "serious", "significant past medical history", "reports", "20 smoking history", "temperature", "36", "98 4F", "pulse", "96 min", "blood pressure", "mm Hg", "respiratory rate", "min", "physical examination", "auscultation", "chest reveals rhonchi", "crepitus", "right lung", "exam", "unremarkable", "chest radiograph reveals", "mass", "the middle lobe of", "right lung", "following clinical signs", "most likely", "present", "patient"]}
{"question": "A 40-year-old obese man with a history of diabetes and chronic kidney disease presents with one day of excruciating pain, swelling, and redness in his greater toe. He denies any inciting trauma or similar prior episodes. Vital signs are stable. On examination, the right first toe is grossly erythematous and edematous, with range of motion limited due to pain. Deposition of which of the following is associated with the most likely underlying joint disorder?", "answer": "Monosodium urate", "options": {"A": "Calcium phosphate", "B": "Calcium oxalate", "C": "Monosodium urate", "D": "Copper"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["40 year old obese man", "history", "diabetes", "chronic kidney disease presents", "one day", "excruciating pain", "swelling", "redness", "greater toe", "denies", "trauma", "similar prior episodes", "Vital signs", "stable", "examination", "right first toe", "erythematous", "edematous", "range of motion limited due to pain", "Deposition", "following", "associated with", "likely", "joint disorder"]}
{"question": "An obese 42-year-old female presents to her primary care physician with a complaint of left knee pain for the past 3 months. She describes the pain as affecting the inside part of the knee as well as the front of her knee, below the kneecap. She denies any inciting injury or trauma to the knee but reports that the pain is worse when she is climbing up stairs or rising from a chair. Physical examination is significant for localized tenderness to palpation over the left anteromedial proximal tibia, 6 cm inferior to the joint line. There is no joint effusion noted. Valgus stress testing is negative for any pain or instability of the knee joint. Radiographs of the left knee are obtained and reveal only mild arthritis, without evidence of any fractures or bony lesions. Which of the following is the most likely diagnosis in this patient?", "answer": "Pes anserine bursitis", "options": {"A": "Stress fracture of proximal tibia", "B": "Medial meniscus tear", "C": "Medical collateral ligament (MCL) sprain", "D": "Pes anserine bursitis"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["obese", "year old female presents", "primary care physician", "complaint", "left", "past 3 months", "pain", "affecting", "part of", "knee", "front", "knee", "kneecap", "denies", "injury", "trauma", "knee", "reports", "pain", "worse", "climbing", "stairs", "rising from a chair", "Physical examination", "significant", "localized tenderness", "palpation", "left anteromedial proximal", "inferior", "joint line", "joint effusion noted", "Valgus stress testing", "negative", "pain", "instability of", "knee joint", "Radiographs", "left", "obtained", "reveal only mild arthritis", "evidence", "fractures", "bony lesions", "following", "most likely diagnosis", "patient"]}
{"question": "A 24-year-old woman comes to the physician’s office with concerns about a recent pregnancy. She and her boyfriend had intercourse for the first time a few weeks ago. Two weeks ago she missed her menstrual period. She took several over the counter pregnancy tests that confirmed her pregnancy. She is tearful about the pregnancy and is very concerned. After extensive conversations with her physician and counseling, she decides she wants to medically abort her 6-week pregnancy. Which of the following drugs should be administered to this patient for this purpose?", "answer": "Mifepristone", "options": {"A": "Tamoxifen", "B": "Terbutaline", "C": "Mifepristone", "D": "Copper intrauterine device"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physicians office", "concerns", "recent pregnancy", "boyfriend", "intercourse", "first time", "few weeks", "Two", "missed", "menstrual period", "took several over the counter pregnancy", "confirmed", "pregnancy", "tearful", "pregnancy", "very concerned", "extensive conversations", "physician", "counseling", "to", "abort", "week pregnancy", "following drugs", "administered", "patient", "purpose"]}
{"question": "A 25-year-old woman comes to the physician because of periodic painful double vision for 3 days. Her symptoms occur only when looking sideways. She has myopia and has been wearing corrective lenses for 10 years. Ten days ago, she lost her balance and fell off her bike, for which she went to a hospital. A CT scan of the head at that time showed no abnormalities and she was released without further treatment. Her only medication is an oral contraceptive. Her vital signs are within normal limits. The pupils are equal and reactive to light. Her best corrected visual acuity is 20/40 in each eye. She has an adduction deficit in the right eye and nystagmus in the left eye when looking left; she has an adduction deficit in the left eye and nystagmus in the right eye when looking right. Fundoscopy reveals bilateral disc hyperemia. Which of the following is the most likely cause of this patient's findings?", "answer": "Demyelination of the medial longitudinal fasciculus", "options": {"A": "Demyelination of the medial longitudinal fasciculus", "B": "Compressive tumor of the pons", "C": "Oxidative damage due to thiamine deficiency", "D": "Infarction of the brainstem"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "physician", "of periodic painful double vision", "3 days", "symptoms occur only", "looking", "myopia", "corrective lenses", "10 years", "Ten days", "lost", "balance", "fell", "bike", "hospital", "CT scan of", "head", "time showed", "abnormalities", "released", "further treatment", "only medication", "oral contraceptive", "vital signs", "normal limits", "pupils", "equal", "reactive to light", "best corrected visual acuity", "20/40", "eye", "adduction deficit", "right eye", "nystagmus", "left eye", "looking left", "adduction deficit", "left eye", "nystagmus", "right eye", "looking right", "Fundoscopy reveals bilateral disc hyperemia", "following", "most likely cause", "patient's findings"]}
{"question": "A 63-year-old man presents to the clinic for left calf pain when walking a distance of more than 200 m. He has had this pain for more than 8 months now, and he rates it as 7 out of 10. The pain subsides with rest. The patient has had a history of diabetes mellitus for the past 2 years which is well controlled. A percutaneous coronary intervention was performed in 2014. His current medications are insulin and aspirin. Family history is significant for coronary artery disease. He has an 80 pack-year history of smoking and currently smokes. He consumes 4 drinks per day of alcohol. On physical examination, his blood pressure is 144/89 mm Hg, the heart rate is 80/min and regular, the breathing rate is 25/min, and the pulse oximetry is 96%. Normal cardiac and lung sounds were heard on auscultation. Which of the following is the appropriate treatment to improve the patient’s symptoms?", "answer": "Cilostazol", "options": {"A": "Cilostazol", "B": "Femoral embolectomy", "C": "Femoral-to-popliteal bypass graft", "D": "Interventional endovascular treatment"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["63 year old man presents", "clinic", "left", "walking", "distance", "200 m", "pain", "months now", "rates", "10", "pain", "rest", "patient", "history of diabetes mellitus", "past", "years", "well controlled", "percutaneous coronary intervention", "performed", "current medications", "insulin", "aspirin", "Family history", "significant", "coronary artery disease", "80 pack-year history of smoking", "currently smokes", "4 drinks per day", "alcohol", "physical examination", "blood pressure", "mm Hg", "heart rate", "80 min", "regular", "breathing rate", "min", "pulse oximetry", "96", "Normal cardiac", "lung sounds", "heard", "auscultation", "following", "appropriate treatment to", "patients symptoms"]}
{"question": "A 72-year-old woman comes to the physician because of a 1-month history of frequent headaches, double vision, fatigue, and myalgias. Physical examination shows pallor, tenderness to palpation over the temples, and inward deviation of the left eye. Laboratory studies show an erythrocyte sedimentation rate of 65 mm/h. Temporal artery biopsy shows transmural granulomatous inflammation and fragmentation of the internal elastic lamina. Treatment with high-dose intravenous corticosteroids is begun. The patient's condition puts her at greatest risk of developing which of the following complications?", "answer": "Thoracic aortic aneurysm", "options": {"A": "Pulmonary hypertension", "B": "Lower extremity gangrene", "C": "Palpable purpura", "D": "Thoracic aortic aneurysm"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["72 year old woman", "physician", "of", "month history", "frequent headaches", "double vision", "fatigue", "myalgias", "Physical examination shows pallor", "tenderness", "palpation", "temples", "inward deviation", "left", "Laboratory studies show", "erythrocyte sedimentation rate of 65 mm/h", "Temporal artery biopsy shows transmural granulomatous inflammation", "fragmentation", "internal elastic lamina", "Treatment", "high-dose intravenous corticosteroids", "begun", "patient's condition puts", "greatest risk", "following complications"]}
{"question": "A 22-year-old woman comes to the physician because of yellow vaginal discharge, pruritus, and pain with urination for the past 6 days. Three weeks ago, she had an episode of acute bacterial rhinosinusitis that was treated with a 10-day course of amoxicillin. She has been sexually active with multiple male partners over the past year and uses condoms inconsistently; she has been taking an oral contraceptive for the past 2 years. She has no previous history of serious illness or sexually transmitted diseases. Her temperature is 37°C (98.6°F), pulse is 75/min, respirations are 12/min, and blood pressure is 122/82 mm Hg. Pelvic examination shows erythema of the vulva and vagina and foul-smelling, frothy, yellow-green vaginal discharge. The pH of the discharge is 5.8. Bimanual examination is unremarkable. Further evaluation of this patient's vaginal discharge is most likely to show which of the following findings?", "answer": "Flagellated protozoa", "options": {"A": "Gram-negative diplococci", "B": "Positive whiff test", "C": "Pseudohyphae", "D": "Flagellated protozoa"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "yellow vaginal discharge", "pruritus", "pain", "urination", "past", "days", "Three weeks", "episode of acute bacterial rhinosinusitis", "treated with", "10 day course", "amoxicillin", "sexually active", "multiple male partners", "past year", "uses condoms", "taking", "oral contraceptive", "past", "years", "previous history", "serious illness", "sexually transmitted diseases", "temperature", "98", "pulse", "75 min", "respirations", "min", "blood pressure", "mm Hg", "Pelvic examination shows erythema of", "vulva", "vagina", "foul-smelling", "frothy", "yellow-green vaginal discharge", "pH", "discharge", "5.8", "Bimanual examination", "unremarkable", "Further evaluation", "patient's vaginal discharge", "most likely to show", "following findings"]}
{"question": "A 15-year-old female presents to her pediatrician’s office for severe menstrual cramping. The patient underwent menarche at age 11, and her periods were irregular every 2-3 months for two years. After that, her cycles became roughly regular every 28-35 days, but she has had extremely painful cramps and often has to miss school. The cramps are intermittent and feel like a dull ache in the center of her abdomen, and there is usually accompanying back pain. The patient has been using heating pads with limited relief. She reports some periods being “really heavy” and requires a superabsorbent pad every 6 hours for 2 days each cycle, but this does not limit her activities. She denies any bowel or bladder changes. The patient had normal development throughout childhood, is on the soccer team at school, and is not sexually active. Her father has hypertension and her mother has endometriosis and heavy periods. On exam, the patient is 5 feet 5 inches and weighs 158 pounds (BMI 26.3 kg/m^2). She is well appearing and has no abdominal tenderness. She has Tanner IV breasts and Tanner IV pubic hair, and external genitalia are normal. Which of the following is the best next step for this patient’s menstrual cramps?", "answer": "NSAIDs", "options": {"A": "Pelvic ultrasound", "B": "MRI of the pelvis", "C": "NSAIDs", "D": "Increased exercise"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old female presents", "pediatricians office", "severe menstrual cramping", "patient", "menarche at age", "periods", "irregular", "2-3 months", "two years", "cycles", "regular", "35 days", "extremely painful cramps", "often", "miss school", "cramps", "intermittent", "feel", "dull ache", "center", "abdomen", "usually", "back pain", "patient", "using heating pads", "limited relief", "reports", "periods", "heavy", "pad", "hours", "days", "cycle", "not limit", "activities", "denies", "bowel", "bladder changes", "patient", "normal", "childhood", "soccer team", "school", "not sexually active", "father", "hypertension", "mother", "endometriosis", "heavy periods", "exam", "patient", "5 feet 5 inches", "pounds", "BMI", "kg/m", "well appearing", "abdominal tenderness", "Tanner IV breasts", "Tanner IV pubic hair", "external genitalia", "normal", "following", "best next step", "patients menstrual cramps"]}
{"question": "A 34-year-old woman is brought to the emergency department following a high-speed motor vehicle collision in which she was the restrained driver. On arrival, she has a cervical collar in place and is unresponsive. Her temperature is 36.7°C (98°F), pulse is 70/min, and blood pressure is 131/76 mm Hg. Her pupils are dilated and not reactive to light. She is unresponsive to noxious stimuli. She is intubated, and mechanical ventilation is begun. Serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. Toxicology screening is negative. A CT scan of the head without contrast shows a massive intracranial bleed and a cervical spine injury at the level of C3. Which of the following is the most appropriate next step in diagnosing brain death?", "answer": "Corneal reflex test", "options": {"A": "Electroencephalography", "B": "Magnetic resonance angiography", "C": "Deep tendon reflex testing", "D": "Corneal reflex test"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "brought", "emergency department following", "high speed motor vehicle collision", "restrained driver", "arrival", "cervical collar", "place", "unresponsive", "temperature", "36", "pulse", "70 min", "blood pressure", "76 mm Hg", "pupils", "dilated", "not reactive to light", "unresponsive to", "stimuli", "intubated", "mechanical ventilation", "begun", "Serum", "electrolytes", "urea nitrogen", "creatinine", "reference range", "Toxicology screening", "negative", "CT scan of", "head", "contrast shows", "massive intracranial", "cervical spine injury", "level of C3", "following", "most appropriate next step", "diagnosing brain death"]}
{"question": "A previously healthy 17-year-old female college student comes to the emergency department because of a 1-day history of fever, chills, and severe headache. Her temperature is 39.4°C (103°F). Physical examination shows nuchal rigidity and photophobia. Blood cultures are obtained and a lumbar puncture is performed. A Gram stain of cerebrospinal fluid shows gram-negative cocci in pairs. Which of the following virulence factors was most likely involved in the initial step of this patient's infection?", "answer": "Adhesive pili", "options": {"A": "Protein A", "B": "Lipooligosaccharides", "C": "Adhesive pili", "D": "Biofilm formation"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old female college student", "emergency department", "1-day history", "fever", "chills", "severe headache", "temperature", "4C", "Physical examination shows nuchal rigidity", "photophobia", "Blood cultures", "obtained", "lumbar puncture", "performed", "Gram stain", "cerebrospinal fluid shows gram-negative cocci", "pairs", "following virulence factors", "most likely involved", "initial step", "patient's infection"]}
{"question": "A 74-year-old man was admitted to the intensive care ward due to progressive dyspnea, cough with pink sputum, and diaphoresis. He had 2 myocardial infarctions at the age of 66 and 69 years and suffers from chronic heart failure. At the time of presentation, his vital signs are as follows: blood pressure 90/50 mm Hg, heart rate 108/min, respiratory rate 29/min, and temperature 35.5°C (95.9°F). On physical examination, the patient sits upright. He is lethargic and cyanotic. Lung auscultation reveals widespread bilateral fine rales. Cardiac examination is significant for S3, accentuation of the pulmonic component of S2, and a systolic murmur heard best at the apex of the heart. Soon after hospitalization, the patient develops ventricular fibrillation and dies despite adequate resuscitation measures. Which microscopic finding would you expect to see in this patient on autopsy?", "answer": "Brownish inclusions in the pulmonary macrophages on H&E staining", "options": {"A": "Brownish inclusions in the pulmonary macrophages on H&E staining", "B": "Positive Prussian-blue staining of the kidney tissue", "C": "Ground-glass hepatocytes", "D": "Positive Congo-red staining of the cardiac tissue"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["74 year old man", "admitted", "intensive care ward", "progressive dyspnea", "cough", "pink sputum", "diaphoresis", "2 myocardial infarctions", "age", "66", "69 years", "suffers", "chronic heart failure", "time", "presentation", "vital signs", "follows", "blood pressure 90 50 mm Hg", "heart rate", "min", "respiratory rate 29 min", "temperature 35", "95 9F", "physical examination", "patient sits upright", "lethargic", "cyanotic", "Lung auscultation reveals widespread bilateral fine rales", "Cardiac examination", "significant", "S3", "pulmonic component", "S2", "systolic murmur heard best", "the apex of", "heart", "hospitalization", "patient", "ventricular fibrillation", "adequate resuscitation measures", "microscopic finding", "to see", "patient", "autopsy"]}
{"question": "Please refer to the summary above to answer this question\nA cardiologist at another institution is trying to replicate the table in the abstract with a very similar study that he is conducting. After collecting data on changes in plaque volume, LDL-C levels, FEV1/FVC ratio, and ACQ scores from baseline to 12-month follow-up, he is curious if the changes in the aforementioned measurements are statistically significant. Which of the following is the most appropriate statistical method to compare the groups?\"\n\"Impact of pulmharkimab on asthma control and cardiovascular disease progression in patients with coronary artery disease and comorbid asthma\nIntroduction:\nActive asthma has been found to be associated with a more than two-fold increase in the risk of myocardial infarction, even after adjusting for cardiovascular risk factors. It has been suggested that the inflammatory mediators and accelerated atherosclerosis characterizing systemic inflammation may increase the risk of both asthma and cardiovascular disease. This study evaluated the efficacy of the novel IL-1 inhibitor pulmharkimab in improving asthma and cardiovascular disease progression.\nMethods:\nIn this double-blind, randomized controlled trial, patients (N=1200) with a history of coronary artery disease, myocardial infarction in the past 2 years, and a diagnosis of comorbid adult-onset asthma were recruited from cardiology clinics at a large academic medical center in Philadelphia, PA. Patients who were immunocompromised or had a history of recurrent infections were excluded.\nPatients were subsequently randomly assigned a 12-month course of pulmharkimab 75 mg/day, pulmharkimab 150 mg/day, or a placebo, with each group containing 400 participants. All participants were included in analysis and analyzed in the groups to which they were randomized regardless of medication adherence. Variables measured included plaque volume, serum LDL-C levels, FEV1/FVC ratio, and Asthma Control Questionnaire (ACQ) scores, which quantified the severity of asthma symptoms. Plaque volume was determined by ultrasound.\nAnalyses were performed from baseline to month 12.\nResults:\nAt baseline, participants in the two groups did not differ by age, gender, race, plaque volume, serum LDL-C levels, FEV1/FVC ratio, and ACQ scores (p > 0.05 for all). A total of 215 participants (18%) were lost to follow-up. At 12-month follow-up, the groups contained the following numbers of participants:\nPulmharkimab 75 mg/d: 388 participants\nPulmharkimab 150 mg/d: 202 participants\nPlacebo: 395 participants\nTable 1: Association between pulmharkimab and both pulmonary and cardiovascular outcomes. Models were adjusted for sociodemographic variables and medical comorbidities. All outcome variables were approximately normally distributed.\nPulmharkimab 75 mg/d, (Mean +/- 2 SE) Pulmharkimab 150 mg/d, (Mean +/- 2 SE) Placebo, (Mean +/- 2 SE) P-value\nPlaque volume (mm3), change from baseline 6.6 ± 2.8 1.2 ± 4.7 15.8 ± 2.9 < 0.01\nLDL-C levels, change from baseline -9.4 ± 3.6 -11.2 ± 14.3 -8.4 ± 3.9 0.28\nFEV1/FVC ratio, change from baseline 0.29 ± 2.21 0.34 ± 5.54 -0.22 ± 3.21 0.27\nACQ scores, change from baseline 0.31 ± 1.22 0.46 ± 3.25 0.12 ± 1.33 0.43\nConclusion:\nPulmharkimab may be effective in reducing plaque volume but does not lead to improved asthma control in patients with a history of myocardial infarction and comorbid asthma.\nSource of funding: Southeast Institute for Advanced Lung and Cardiovascular Studies, American Center for Advancement of Cardiovascular Health\"", "answer": "Analysis of variance", "options": {"A": "Pearson correlation analysis", "B": "Chi-square test", "C": "Analysis of variance", "D": "Kaplan-Meier analysis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["refer", "summary above to answer", "question", "cardiologist", "institution", "to replicate", "table", "abstract", "very similar study", "conducting", "collecting data", "changes", "plaque volume", "levels", "FEV1/FVC ratio", "ACQ scores", "baseline", "month follow-up", "curious", "changes", "measurements", "statistically significant", "following", "most appropriate statistical method to compare", "groups", "Impact", "asthma control", "cardiovascular", "patients", "coronary artery disease", "comorbid asthma Introduction", "Active asthma", "found to", "associated with", "two fold increase", "risk", "myocardial infarction", "cardiovascular risk factors", "suggested", "inflammatory mediators", "accelerated atherosclerosis", "systemic inflammation", "increase", "risk", "asthma", "cardiovascular disease", "study evaluated", "efficacy", "novel IL-1 inhibitor", "improving asthma", "cardiovascular", "Methods", "double-blind", "randomized controlled trial", "patients", "N", "history of coronary artery disease", "myocardial infarction", "past", "years", "diagnosis", "comorbid adult-onset asthma", "cardiology clinics", "large academic medical center", "Philadelphia", "PA", "Patients", "immunocompromised", "history", "recurrent infections", "excluded", "Patients", "assigned", "month course", "75 mg/day", "mg/day", "placebo", "group containing 400 participants", "participants", "included", "analysis", "analyzed", "groups", "randomized regardless", "medication adherence", "Variables measured included plaque volume", "serum LDL", "levels", "FEV1/FVC ratio", "Asthma Control Questionnaire", "scores", "quantified", "severity of asthma symptoms", "Plaque volume", "determined by ultrasound", "Analyses", "performed", "baseline", "month", "Results", "baseline", "participants", "two groups", "not", "age", "gender", "race", "plaque volume", "serum LDL", "levels", "FEV1/FVC ratio", "ACQ scores", "p", "0.05", "total", "participants", "lost to follow-up", "month follow-up", "groups contained", "following numbers", "participants", "75 mg/d", "participants", "mg/d", "participants Placebo", "participants Table", "Association", "pulmonary", "cardiovascular outcomes", "Models", "adjusted", "variables", "medical comorbidities", "outcome variables", "approximately", "distributed", "75 mg/d", "Mean", "SE", "mg/d", "Mean", "SE", "Placebo", "Mean", "SE", "P-value Plaque volume", "mm3", "change", "baseline", "0.01", "levels", "change", "baseline", "0", "FEV1/FVC ratio", "change", "baseline 0.29", "54", "27 ACQ scores", "change", "baseline 0.31", "Conclusion", "effective", "reducing plaque volume", "not lead", "improved asthma control", "patients", "history of myocardial infarction", "comorbid asthma", "Source", "funding", "Southeast Institute", "Advanced Lung", "Cardiovascular Studies", "American Center", "Advancement", "Cardiovascular Health"]}
{"question": "A 35-year-old woman comes to the physician because of intermittent episodes of heart palpitations for 3 weeks. The palpitations are accompanied by chest pain that is sharp and localized to the left 3rd intercostal space. The patient does not smoke. She drinks one to two glasses of wine on the weekends. She appears nervous. Her pulse is 110/min and irregularly irregular, and blood pressure is 135/85 mmHg. Examination shows a fine tremor on both hands and digital swelling. There is retraction of the left upper eyelid. A systolic ejection murmur is heard along the right upper sternal border. The extremities are warm, and pulses are 2+ bilaterally. Which of the following is the most appropriate pharmacotherapy?", "answer": "Propranolol", "options": {"A": "Propranolol", "B": "Digoxin", "C": "Amiodarone", "D": "Warfarin"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "physician", "of intermittent episodes", "heart palpitations", "3 weeks", "palpitations", "chest pain", "sharp", "localized", "left 3rd intercostal space", "patient", "not smoke", "drinks one", "two glasses", "wine", "weekends", "appears nervous", "pulse", "min", "irregular", "blood pressure", "85 mmHg", "Examination shows", "fine", "hands", "digital swelling", "retraction of", "left upper eyelid", "systolic ejection murmur", "heard", "right upper sternal border", "extremities", "warm", "pulses", "2", "following", "most appropriate pharmacotherapy"]}
{"question": "A 78-year-old right-handed man is brought to the emergency department by his daughter for sudden onset speech changes. The patient lives with his daughter and was chatting with her when suddenly his speech became distorted with random and disconnected words that made no sense. He seems to be physically frustrated that no one understands him. Physical examination demonstrates weakness of the right arm. Damage to which location would best explain this patient’s symptoms?", "answer": "Left frontal lobe", "options": {"A": "Left frontal lobe", "B": "Left temporal lobe", "C": "Right frontal lobe", "D": "Right temporal lobe"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old right-handed man", "brought", "emergency department", "daughter", "sudden onset speech changes", "patient lives with", "daughter", "chatting", "speech", "distorted", "random", "disconnected words", "made", "sense", "to", "frustrated", "understands", "Physical examination demonstrates weakness of", "right arm", "Damage", "location", "best", "patients symptoms"]}
{"question": "A 68-year-old woman presents with an intermittent throbbing headache with an onset approximately 3 weeks ago. The pain is bilateral, “band-like,” and extends to the neck. The patient rates the 4 points out of 10 on a visual scale. The headache is not accompanied by nausea, vomiting, photophobia, or phonophobia, and is not aggravated by movements, but gets worse when the patient coughs or laughs. The headache has persisted throughout the day and is usually worse in the morning an hour after she has breakfast and taken her medications. The patient was diagnosed with stage 1 arterial hypertension 2 years ago and stable angina pectoris 3 weeks ago. Currently, she takes aspirin (81 mg once daily), rosuvastatin (10 mg once daily), lisinopril (20 mg once daily), and isosorbide mononitrate (60 mg once daily). She has been menopausal for the last 15 years. In addition to her chief complaint, she also notes that she had a runny nose with a temperature elevation approximately 3 weeks ago, and her headache was linked to that acute illness. The vital signs are as follows: blood pressure 135/80 mm Hg, heart rate 76/min, respiratory rate 14/min, and temperature 36.5℃ (97.7℉). The physical examination reveals S2 accentuation that is best heard in the second intercostal space at the right sternal border. Palpation of the paranasal sinuses is painless. The neurologic exam shows no focal symptoms, no pain on palpation of the trigeminal points, and no meningeal symptoms. What is the most likely mechanism underlying the patient’s headaches?", "answer": "Dilation of the intracerebral arterioles", "options": {"A": "Meningeal irritation by blood products originating from a chronic subdural hematoma", "B": "Dissection of an intracerebral vessel", "C": "Meningeal irritation by a growing intracranial neoplasm", "D": "Dilation of the intracerebral arterioles"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["68 year old woman presents", "intermittent throbbing", "onset approximately", "weeks", "pain", "bilateral", "band", "extends", "neck", "patient rates", "4 points out", "10", "visual scale", "headache", "not", "nausea", "vomiting", "photophobia", "phonophobia", "not aggravated", "movements", "gets worse", "patient coughs", "laughs", "headache", "day", "usually worse", "morning", "hour", "breakfast", "taken", "medications", "patient", "diagnosed", "stage arterial hypertension 2 years", "stable angina pectoris", "weeks", "Currently", "takes aspirin", "81 mg", "daily", "rosuvastatin", "10 mg", "daily", "lisinopril", "20 mg", "daily", "isosorbide mononitrate", "60 mg", "daily", "menopausal", "years", "chief complaint", "notes", "runny nose", "temperature elevation approximately", "weeks", "headache", "linked", "acute illness", "vital signs", "follows", "blood pressure", "80 mm Hg", "heart rate 76 min", "respiratory rate", "min", "temperature 36", "97", "physical examination reveals S2", "best heard", "second intercostal space", "right sternal border", "Palpation", "paranasal sinuses", "painless", "neurologic exam shows", "focal symptoms", "pain", "palpation", "points", "meningeal symptoms", "most likely mechanism", "patients headaches"]}
{"question": "A 31-year-old male comes to your office for his annual exam. He states that he received all of his recommended vaccinations prior to beginning college, but has not had any vaccines in the past 13 years. His medical history is significant for intermittent, exercise-induced asthma. He has been sexually active in the past with multiple female partners. In addition to an influenza vaccine, which vaccine should be administered to this patient during this visit?", "answer": "Tetanus, diphtheria, and acellular pertussis booster (Tdap) vaccine", "options": {"A": "Pneumococcal vaccine", "B": "Tetanus, diphtheria, and acellular pertussis booster (Tdap) vaccine", "C": "Haemophilus influenza B (HIB) vaccine", "D": "Human papillomavirus (HPV) vaccine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["31 year old male", "office", "annual exam", "states", "received", "recommended vaccinations", "beginning college", "not", "vaccines", "past", "years", "medical history", "significant", "intermittent", "exercise-induced asthma", "sexually active", "past", "multiple female partners", "influenza vaccine", "vaccine", "administered", "patient", "visit"]}
{"question": "A 24-year-old woman presents to the emergency department with a 2-week history of a foot ulcer. She says that she punctured her foot with a rusty nail while she was playing tennis and that the puncture wound has since progressed to a non-healing ulcer. Over the last 2 days, she has also been experiencing a fever and drainage from the wound. On presentation, she is found to have a slightly fruity smelling red ulcer with purulent drainage. Probing the ulcer goes all the way down to bone. Which of the following characteristics is true of the most likely cause of this patient's symptoms?", "answer": "Gram-negative bacilli", "options": {"A": "Gram-negative bacilli", "B": "Gram-negative diplococci", "C": "Gram-positive cocci in chains", "D": "Gram-positive cocci in clusters"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "2-week history of", "foot ulcer", "punctured", "foot", "rusty nail", "playing tennis", "puncture wound", "since progressed", "non", "last 2 days", "experiencing", "fever", "drainage", "wound", "presentation", "found to", "slightly fruity smelling red ulcer", "purulent drainage", "Probing", "ulcer goes", "bone", "following characteristics", "true", "likely cause", "patient's symptoms"]}
{"question": "A 23-year-old man comes to the physician because of a 1-week history of anorexia, nausea, upper abdominal pain, and dark-colored urine. He recently returned from a trip to Belize. His temperature is 38.3°C (100.9°F). Physical examination shows scleral icterus and tender hepatomegaly. Serum studies show markedly elevated transaminases and anti-hepatitis A virus antibodies. In this patient, infected cells express more MHC class I molecules on their surfaces. This cellular event is primarily induced by a molecule that is also responsible for which of the following changes?", "answer": "Increased breakdown of intracellular RNA", "options": {"A": "Upregulated expression of exogenously synthesized antigens", "B": "Enhanced macrophage phagocytic function", "C": "Activation of eukaryotic initiation factor 2", "D": "Increased breakdown of intracellular RNA"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["23 year old man", "physician", "1-week history", "anorexia", "nausea", "upper abdominal pain", "dark-colored urine", "recently returned", "trip", "Belize", "temperature", "3C", "100 9F", "Physical examination shows scleral icterus", "tender hepatomegaly", "Serum studies show markedly elevated transaminases", "hepatitis A virus antibodies", "patient", "infected cells", "more MHC class I molecules", "surfaces", "cellular event", "induced", "molecule", "responsible", "following changes"]}
{"question": "A 42-year-old man comes to the physician because of progressive fatigue and shortness of breath for 1 month. He has been unable to practice with his recreational soccer team and has had to rest frequently when walking to work. His only medication is ibuprofen for joint pain. Physical examination shows tanned skin. There is tenderness to palpation and stiffness of the metacarpophalangeal joints of both hands. Pulmonary examination shows coarse crackles in both lung fields. The liver is palpated 4 cm below the right costal margin. Human leukocyte antigen (HLA) testing is most likely to be positive for which of the following?", "answer": "HLA-A3", "options": {"A": "HLA-DR3", "B": "HLA-DR4", "C": "HLA-B8", "D": "HLA-A3"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "progressive fatigue", "shortness of breath", "1 month", "unable to practice", "recreational soccer team", "to rest frequently", "walking to work", "only medication", "ibuprofen", "joint pain", "Physical examination shows tanned skin", "tenderness", "palpation", "stiffness of", "joints of", "hands", "Pulmonary examination shows coarse crackles", "lung fields", "liver", "palpated 4 cm", "right costal margin", "Human leukocyte antigen", "testing", "most likely to", "positive"]}
{"question": "A 32-year-old Caucasian woman is referred to a gastroenterologist by her family physician for 8 months of abdominal pain, foul-smelling diarrhea with floating, bulky stools, weight loss, and macrocytic anemia. Her personal history is relevant for allergic rhinitis. Physical examination shows grouped, erythematous papulovesicular lesions on her arms, torso, and abdomen. Which of the following is the most appropriate approach for the management of this patient?", "answer": "Gluten-free diet", "options": {"A": "Amitriptyline", "B": "Octreotide", "C": "Gluten-free diet", "D": "Methysergide maleate"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old Caucasian woman", "referred", "gastroenterologist", "family physician", "months", "abdominal pain", "smelling diarrhea", "floating", "bulky stools", "weight loss", "macrocytic anemia", "personal history", "relevant", "allergic rhinitis", "Physical examination shows grouped", "erythematous papulovesicular lesions", "arms", "torso", "abdomen", "following", "most appropriate approach", "management", "patient"]}
{"question": "A 62-year-old woman with small-cell lung cancer comes to the physician because of a painful, burning red rash on her face and hands that developed 30 minutes after going outside to do garden work. She wore a long-sleeved shirt and was exposed to direct sunlight for about 10 minutes. The patient is light-skinned and has a history of occasional sunburns when she does not apply sunscreen. Current medications include demeclocycline for malignancy-associated hyponatremia and amoxicillin for sinusitis. Physical examination shows prominent erythema and a papular eruption on her forehead, cheeks, neck, and the dorsum of both hands. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Cell injury due to drug metabolites", "options": {"A": "Degranulation of presensitized mast cells", "B": "Formation of drug-induced autoantibodies", "C": "Accumulation of porphobilinogen", "D": "Cell injury due to drug metabolites"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old woman", "small-cell lung cancer", "physician", "painful", "burning red rash on", "face", "hands", "30 minutes", "outside", "garden work", "long sleeved shirt", "exposed to direct sunlight", "10 minutes", "patient", "light skinned", "history", "occasional sunburns", "not apply sunscreen", "Current medications include demeclocycline", "malignancy associated hyponatremia", "amoxicillin", "sinusitis", "Physical examination shows prominent erythema", "papular eruption", "forehead", "cheeks", "neck", "dorsum of", "hands", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 54-year-old man is brought to the emergency department after he was found outside in the middle of a blizzard. On presentation, he is conscious but does not know where he is nor how he got there. His wife is contacted and says that he has been getting increasingly confused over the past 6 weeks. This progressed from misplacing objects to getting lost in places that he knew how to navigate previously. Most worryingly, he has recently started forgetting the names of their children. In addition to these memory changes, she says that he now has rapid jerky movements of his extremities as well as coordination and balance problems. Finally, he has become extremely paranoid about government surveillance and has had hallucinations about secret agents in their house. His previous medical history is significant for a previous car crash in which the patient required internal fixation of a femur fracture and a corneal transplant for corneal degeneration. Otherwise he had no neurologic deficits prior to 6 weeks ago. Physical exam reveals myoclonus and ataxia. Which of the following is true of the most likely cause of this patient's symptoms?", "answer": "Can be transmitted on medical equipment even after autoclaving instruments", "options": {"A": "Can be transmitted on medical equipment even after autoclaving instruments", "B": "Contains genetic material but is unable to survive independent from a host", "C": "Has a cell wall containing peptidoglycan", "D": "Leads to intracellular aggregations of hyperphosphorylated tau protein"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["54 year old man", "brought", "emergency department", "found outside", "middle", "blizzard", "presentation", "conscious", "not", "got", "wife", "contacted", "getting", "confused", "past", "weeks", "progressed", "objects", "getting lost", "places", "to", "recently started forgetting", "names", "children", "memory changes", "now", "rapid jerky", "extremities", "coordination", "balance problems", "extremely", "government surveillance", "hallucinations", "secret agents", "house", "previous medical history", "significant", "previous car crash", "patient required internal fixation of", "femur fracture", "corneal", "degeneration", "neurologic deficits prior to", "weeks", "Physical exam reveals myoclonus", "ataxia", "following", "true", "likely cause", "patient's symptoms"]}
{"question": "A 5-year-old boy is brought to his pediatrician due to sore throat and fever. He was in his usual state of health until 3 days ago when he began to complain of a sore throat as well as general malaise. The patient's past medical history reveals recurrent upper respiratory infections but no skin or soft tissue infections. The child had cardiac surgery as an infant but has otherwise been healthy. On presentation, his temperature is 100°F (37.8 °C), blood pressure is 115/72 mmHg, pulse is 65/min, and respirations are 22/min. Physical exam shows white plaques on the tongue and mouth. A scraping of this material reveals a characteristic morphology after being treated with KOH. Serum protein electrophoresis shows a normal distribution of bands from this patient. Which of the following findings would most likely be found in this patient?", "answer": "Hypoparathyroidism", "options": {"A": "Delayed separation of the umbilical cord", "B": "Hypoparathyroidism", "C": "Partial albinism", "D": "Thrombocytopenic purpura"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["5 year old boy", "brought", "pediatrician", "sore throat", "fever", "usual state of health", "3 days", "began to", "sore throat", "general malaise", "patient's past reveals recurrent upper respiratory infections", "skin", "soft tissue infections", "child", "cardiac surgery", "infant", "healthy", "presentation", "temperature", "blood pressure", "72 mmHg", "pulse", "65 min", "respirations", "min", "Physical exam shows white plaques on", "tongue", "mouth", "scraping", "material reveals", "characteristic morphology", "treated with KOH", "Serum protein electrophoresis shows", "normal distribution", "bands", "patient", "following findings", "most likely", "found", "patient"]}
{"question": "A 35-year-old woman comes to the physician for sleeping problems and the inability to concentrate for 3 months. She says she is worried because she and her husband have been trying to conceive for more than a year with no success. Conception by in vitro fertilization was attempted once 3 months ago but was unsuccessful. Analysis of her husband's semen has shown normal sperm counts and morphology. She has a 6-year-old daughter who was born at term after an uncomplicated pregnancy. She has no history of severe illness and tries to stay healthy by going to the gym an hour per day. Her menses occur at regular 28-day intervals and last 5 to 6 days; her last menstrual period started 2 days ago. Physical examination shows no abnormalities. Which of the following is the most likely cause of this patient's inability to conceive?", "answer": "Diminished ovarian reserve", "options": {"A": "Pelvic inflammatory disease", "B": "Diminished ovarian reserve", "C": "Hypogonadotropic hypogonadism", "D": "Premature ovarian failure"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["35 year old woman", "physician", "sleeping problems", "to concentrate", "months", "worried", "husband", "to", "year", "success", "Conception", "in vitro fertilization", "attempted once", "months", "unsuccessful", "Analysis", "husband's semen", "shown normal sperm counts", "morphology", "year old daughter", "born", "term", "uncomplicated pregnancy", "history", "severe illness", "to", "healthy", "hour", "day", "menses occur", "regular", "day intervals", "last 5", "days", "last menstrual period started 2 days", "Physical examination shows", "abnormalities", "following", "most likely cause", "patient's", "to"]}
{"question": "A 25-year-old female is brought to the emergency department by her family. They found her somnolent next to her computer and scattered pill bottles over two hours ago. The family cannot recall the types of pill bottles that they found and did not bring them to the ED. The patient's past medical history is notable for anxiety, obesity, hypertension, and polycystic ovarian syndrome. She is currently not on any medications other than an exercise program with which she is non-compliant. A physical exam is performed and is within normal limits. The patient begins communicating with the physician and states that she did take acetaminophen but it was only a few pills. Her temperature is 99.5°F (37.5°C), pulse is 82/min, blood pressure is 125/85 mmHg, respirations are 11/min, and oxygen saturation is 97% on room air. Which of the following is the next best step in management?", "answer": "N-acetylcysteine", "options": {"A": "N-acetylcysteine", "B": "Charcoal", "C": "IV fluids", "D": "Syrup of ipecac"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old female", "brought", "emergency department", "family", "found", "somnolent next to", "computer", "scattered pill bottles", "two hours", "family", "recall", "types", "pill bottles", "found", "not", "ED", "patient's past", "notable", "anxiety", "obesity", "hypertension", "polycystic ovarian syndrome", "currently not", "medications other", "exercise program", "non-compliant", "physical exam", "performed", "normal limits", "patient begins communicating", "physician", "states", "take acetaminophen", "only", "few pills", "temperature", "99", "pulse", "min", "blood pressure", "85 mmHg", "respirations", "min", "oxygen saturation", "97", "room air", "following", "next best step", "management"]}
{"question": "A 27-year-old man and his wife come to the physician for preconception genetic counseling. The patient and his wife are asymptomatic and have no history of serious illness. The patient's older brother died at age 13 from heart failure and his 6-year-old nephew currently has severe muscle weakness. Genetic testing in the patient's family shows that his mother is not a carrier of the mutation that is responsible for the disease in his relatives. A pedigree chart of the patient's family is shown. Which of the following is the most likely explanation for the patient not being affected?", "answer": "Gonadal mosaicism", "options": {"A": "Variable expressivity", "B": "Maternal uniparental disomy", "C": "Gonadal mosaicism", "D": "Incomplete penetrance"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old man", "wife", "physician", "preconception genetic", "patient", "wife", "asymptomatic", "history", "serious illness", "patient's older brother died", "age", "heart failure", "year old nephew currently", "severe muscle weakness", "Genetic testing", "patient's family shows", "mother", "not", "carrier", "mutation", "responsible", "disease", "relatives", "pedigree chart", "patient's family", "shown", "following", "most likely explanation", "patient not", "affected"]}
{"question": "A 58-year-old Caucasian female presents to her primary care physician with concerns about several recent health changes. The patient has recently gained weight and can't seem to exercise like she used to. She also notes that her thinking seems slow. Physical examination shows thickened, dry skin. Serum analysis confirms the physician's suspicions. Which of the following findings was most helpful in the diagnosis?", "answer": "High TSH", "options": {"A": "High T4 and T3", "B": "Low T4 and T3", "C": "High TSH", "D": "Hypercholesterolemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old Caucasian female presents", "primary care physician", "concerns", "recent health changes", "patient", "recently gained weight", "to exercise", "used to", "notes", "thinking", "slow", "Physical examination shows thickened", "dry", "Serum analysis confirms", "physician's suspicions", "following findings", "most helpful", "diagnosis"]}
{"question": "A 33-year-old woman at 17-weeks gestation comes to the physician for evaluation of a painless mass in the right breast for the last 3 weeks that has not increased in size. Physical examination shows dense breasts and a 2.5-cm rubbery, mobile mass that is nontender in the upper outer quadrant of the right breast. A biopsy of the mass shows rounded contour with overgrowth of fibrous and glandular tissue. Which of the following is the most likely diagnosis?", "answer": "Fibroadenoma", "options": {"A": "Fibroadenoma", "B": "Normal pregnancy-related changes", "C": "Fat necrosis", "D": "Phyllodes tumor"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "weeks", "physician", "evaluation", "painless mass", "right breast", "weeks", "not increased in size", "Physical examination shows dense breasts", "2.5", "rubbery", "mobile mass", "nontender", "upper outer quadrant of", "right breast", "biopsy", "mass shows rounded contour", "overgrowth", "fibrous", "glandular tissue", "following", "most likely diagnosis"]}
{"question": "A 27-year-old male presents for emergency surgery to reattach his left arm, severed during a high-speed car accident, and has lost significant amounts of blood. His wife arrives within minutes to the hospital exclaiming that under no circumstance should he receive any blood transfusions during surgery. After reviewing his medical chart, you see also see an annotation indicating no blood transfusions for religious reasons. Knowing that he needs a blood transfusion to save his life, what do you do?", "answer": "Respect the patient's written instructions and do not adminster a blood transfusion", "options": {"A": "Administer a blood transfusion to save the patient's life", "B": "Call the ethics board of the hospital to discuss the issue", "C": "Respect the patient's written instructions and do not adminster a blood transfusion", "D": "Convince the wife to administer a blood transfusion to her husband"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["27 year old male presents", "emergency surgery to", "left arm", "severed", "high speed car accident", "lost significant amounts", "blood", "wife", "minutes", "hospital", "receive", "blood transfusions", "surgery", "reviewing", "medical chart", "see", "see", "annotation", "blood transfusions", "religious reasons", "needs", "blood transfusion", "save", "life"]}
{"question": "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?", "answer": "Increase the frequency of blood glucose checks.", "options": {"A": "Increase the frequency of blood glucose checks.", "B": "Reduce the insulin dose.", "C": "Continue same regimen.", "D": "Hold insulin until the patient gets better."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["parents", "year old patient", "concerned", "questions", "use of insulin", "sons recently diagnosed type 1 diabetes", "patient", "upper respiratory infection", "school", "coughing", "runny nose", "temperature", "100", "F", "vital signs", "normal", "Physical examination", "unremarkable", "following modifications", "insulin regimen", "recommend", "patient", "parents"]}
{"question": "A researcher evaluates healthy breast tissue from 100 women, 50 women that were pregnant at the time of the study and 50 age-matched non-pregnant women. The breast tissue in pregnant women contained an increased number of acinar glands with epithelial proliferation compared to the non-pregnant women. Which process caused this change?", "answer": "Hyperplasia", "options": {"A": "Hyperplasia", "B": "Hypertrophy", "C": "Atrophy", "D": "Metaplasia"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["researcher evaluates healthy breast", "100 women", "50 women", "pregnant", "time", "study", "50 age matched non pregnant women", "breast tissue", "pregnant women contained", "increased number", "acinar glands", "epithelial proliferation compared", "non pregnant women", "process caused", "change"]}
{"question": "A 21-month-old boy is brought to the physician for a well-child examination. His mother noticed deformities in both of his legs since he started walking independently. He has been healthy apart from an upper respiratory tract infection 6 months ago. He was delivered at 38 weeks' gestation. His 6-year-old sister was treated for developmental dysplasia of the hip. He can kick a ball and say a 2-word phrase. He plays well with other children at his day care. His immunizations are up-to-date. He is at the 40th percentile for height and 50th percentile for weight. Vital signs are within normal limits. Examination shows closed anterior and posterior fontanelles. The knees do not stay together when both the feet and ankles are placed together. The gait is unremarkable. The mother is concerned that he has a growth disorder. Which of the following is the most appropriate next step in management?", "answer": "Reassurance and follow-up", "options": {"A": "Vitamin D supplementation", "B": "Reassurance and follow-up", "C": "X-ray of the lower extremities", "D": "Bracing of the lower extremities"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "physician", "well", "mother", "deformities", "of", "legs", "started walking", "healthy", "upper respiratory tract infection", "months", "delivered", "weeks", "gestation", "year old sister", "treated", "developmental dysplasia of the hip", "ball", "2 word phrase", "plays well", "children", "day care", "immunizations", "date", "percentile", "height", "50th percentile", "weight", "Vital signs", "normal limits", "Examination shows closed anterior", "posterior fontanelles", "knees", "not", "together", "feet", "ankles", "placed together", "gait", "unremarkable", "mother", "concerned", "growth disorder", "following", "most appropriate next step", "management"]}
{"question": "A 30-year-old woman presents to an outpatient clinic for a scheduled gynecologic check-up. The patient appears well and has no specific complaints. She is current with her Pap smears, all of which have been normal. Her menstrual periods are regular and usually last 3–4 days. She denies any recent travel or a history of trauma. The patient has not been sexually active for the past 2 months. She smokes 1 pack of cigarettes per day and drinks alcohol occasionally, but has never used illicit drugs. The pelvic examination reveals a small, firm, non-tender, immobile cystic mass at the edge of the exocervical os with a yellow hue. The patient is otherwise asymptomatic and has no other complaints. The remainder of the physical examination is unremarkable. Which of the following is the next best step in management?", "answer": "No further intervention", "options": {"A": "No further intervention", "B": "Colposcopy and biopsy", "C": "Administration of oral contraceptives", "D": "Administration of antibiotics"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old woman presents", "outpatient clinic", "scheduled gynecologic check-up", "patient appears well", "specific complaints", "current", "Pap smears", "normal", "menstrual periods", "regular", "usually last", "days", "denies", "recent travel", "history", "trauma", "patient", "not", "sexually active", "past", "months", "smokes 1 pack", "cigarettes", "day", "drinks alcohol occasionally", "never used illicit drugs", "pelvic examination reveals", "small", "firm", "non-tender", "immobile cystic mass", "edge", "exocervical os", "yellow hue", "patient", "asymptomatic", "complaints", "physical examination", "unremarkable", "following", "next best step", "management"]}
{"question": "A 1900-g (4-lb 3-oz) newborn is delivered at term to a 36-year-old primigravid woman. Pregnancy was complicated by polyhydramnios. Apgar scores are 7 and 7 at 1 and 5 minutes, respectively. He is at the 2nd percentile for head circumference and 15th percentile for length. Examination shows a prominent posterior part of the head. The ears are low-set and the jaw is small and retracted. The fists are clenched, with overlapping second and third fingers. The calcaneal bones are prominent and the plantar surface of the foot shows a convex deformity. Abdominal examination shows an omphalocele. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Ventricular septal defect", "options": {"A": "Ventricular septal defect", "B": "Ebstein's anomaly", "C": "Pheochromocytoma", "D": "Holoprosencephaly"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["g", "oz", "newborn", "delivered", "term", "36 year old primigravid woman", "Pregnancy", "complicated", "polyhydramnios", "Apgar scores", "5 minutes", "2nd percentile", "head circumference", "percentile", "length", "Examination shows", "prominent posterior part of", "head", "ears", "low-set", "jaw", "small", "retracted", "fists", "overlapping second", "third fingers", "calcaneal bones", "prominent", "plantar surface of", "foot shows", "convex deformity", "Abdominal examination shows", "omphalocele", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "A 51-year-old man presents to his primary care provider complaining of fatigue, weight loss, and intermittent fevers for the past 6 months. He has had sexual intercourse with multiple men and women over the past year and does not use barrier protection. His last screen for sexually transmitted diseases was 10 years ago and was normal. His past medical history is notable for well-controlled asthma. He was involved in a motorcycle accident 2 years ago and suffered multiple fractured bones in his upper and lower extremities, all of which have healed. He has a distant history of cocaine abuse. He drinks 5-6 glasses of wine per week. His temperature is 100.8°F (38.2°C), blood pressure is 130/75 mmHg, pulse is 85/min, and respirations are 20/min. On examination, he appears cachectic but is pleasant and appropriately interactive. An HIV differentiation assay and follow-up Western blot are performed and are positive. The patient is started on tenofovir, abacavir, and efavirenz. However, the patient develops a hypersensitivity reaction to abacavir, so the decision is made to replace this medication with ritonavir. Which of the following adverse effects is this patient at greatest risk for as a result of this change in medication regimen?", "answer": "Lipodystrophy", "options": {"A": "Hepatotoxicity", "B": "Lipodystrophy", "C": "Myelosuppression", "D": "Peripheral neuropathy"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man presents", "primary care provider", "fatigue", "weight loss", "intermittent fevers", "past 6 months", "sexual intercourse", "multiple men", "women", "past year", "not use barrier protection", "last screen", "sexually transmitted diseases", "10 years", "normal", "past medical history", "notable", "well-controlled asthma", "involved", "motorcycle accident", "years", "suffered multiple fractured bones", "upper", "lower extremities", "healed", "distant history of cocaine abuse", "drinks 5-6 glasses", "wine", "week", "temperature", "100", "blood pressure", "75 mmHg", "pulse", "85 min", "respirations", "20 min", "examination", "appears cachectic", "pleasant", "interactive", "HIV differentiation assay", "follow-up Western blot", "performed", "positive", "patient", "started", "tenofovir", "abacavir", "efavirenz", "patient", "hypersensitivity reaction", "abacavir", "decision", "made to replace", "medication", "ritonavir", "following adverse effects", "patient", "greatest risk", "result", "change", "medication regimen"]}
{"question": "A 68-year-old man presents to his primary care physician with complaints of increased fatigue and back pain for the past year. His symptoms are progressively getting worse over the past few months despite adequate rest and trial of over the counter analgesics. His back pain is constant and non-radiating in nature. He denies any trauma to his back. His past medical history is insignificant. On examination, there is mild tenderness over the lumbar region in the midline with an absence of paraspinal muscle tenderness. Straight leg raise test is negative. His skin and conjunctiva appear pale. The physician orders basic blood work. His results are provided below.\nComplete blood count\nRBC 4.9 million cells/µL\nHemoglobin 9.8 g/dL\nHematocrit 41%\nTotal leukocyte count 6,800 cells/µL\nNeutrophils 70%\nLymphocyte 26%\nMonocytes 3%\nEosinophil 1%\nBasophils 0%\nPlatelets 230,000 cells/µL\nBasic Metabolic Panel\nSodium 136 mEq/L\nPotassium 5.1 mEq/L\nChloride 101 mEq/L\nBicarbonate 24 mEq/L\nAlbumin 3.6 mg/ dL\nUrea nitrogen 31 mg/dL\nCreatinine 2.7 mg/dL\nUric Acid 6.7 mg/dL\nCalcium 12.1 mg/dL\nGlucose 105 mg/dL\nUrinalysis shows proteinuria without any RBCs or pus cells. The patient’s proteinuria best fits in which of the following category?", "answer": "Overflow proteinuria", "options": {"A": "Overflow proteinuria", "B": "Transient (functional) proteinuria", "C": "Orthostatic proteinuria", "D": "Isolated proteinuria"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["68 year old man presents", "primary care physician", "complaints", "increased fatigue", "back pain", "past year", "symptoms", "getting worse", "past", "months", "adequate rest", "trial", "over the counter analgesics", "back pain", "constant", "non radiating", "nature", "denies", "trauma", "back", "past medical history", "examination", "mild tenderness", "lumbar region", "midline", "absence of paraspinal muscle tenderness", "Straight leg raise test", "negative", "skin", "conjunctiva appear pale", "physician orders basic blood work", "results", "provided", "Complete blood", "Panel", "Urinalysis shows proteinuria", "RBCs", "pus cells", "patients proteinuria best fits", "following category"]}
{"question": "A 68-year-old postmenopausal woman presents to the clinic for a dual-energy X-ray absorptiometry (DEXA) scan. The patient states that she has mild joint pain, which she attributes to osteoarthritis, but she notes no recent fractures. She says that her mother had osteoporosis and she is concerned that she may develop it as well. She takes calcium and vitamin D supplements daily. After review of her DEXA scan, her physician states that she has osteopenia. Which of the following is this patient’s most likely DEXA scan result?", "answer": "T-score of -1.6", "options": {"A": "T-score of 1.2", "B": "T-score of -0.8", "C": "Z-score of -2.0", "D": "T-score of -1.6"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["68 year old postmenopausal woman presents", "clinic", "dual-energy X-ray absorptiometry", "scan", "patient states", "mild joint", "attributes", "osteoarthritis", "notes", "recent fractures", "mother", "osteoporosis", "concerned", "well", "takes calcium", "vitamin D supplements daily", "review", "DEXA scan", "physician states", "osteopenia", "following", "patients", "likely DEXA scan result"]}
{"question": "An investigator is studying the growth pattern of a particular bacterial strain that caused a respiratory disease outbreak in children in rural Venezuela. The bacteria are found to be able to grow in a specialized culture that contains sheep blood, cystine, and potassium tellurite; the colonies are black and have a shining surface. The isolated bacteria are most likely which of the following?", "answer": "Corynebacterium diphtheriae", "options": {"A": "Legionella pneumophila", "B": "Haemophilus influenzae", "C": "Bordetella pertussis", "D": "Corynebacterium diphtheriae"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["investigator", "studying", "growth", "bacterial strain", "caused", "respiratory", "children", "rural Venezuela", "bacteria", "found to", "able to", "specialized culture", "contains sheep blood", "cystine", "potassium tellurite", "colonies", "black", "surface", "isolated bacteria", "most likely", "following"]}
{"question": "A 7-month-old boy is brought to the physician because of a 2-month history of fatigue, weakness, and difficulty feeding. He was delivered at term to a 32-year-old woman. He is not able to sit upright on his own. He is at the 75th percentile for height and 25th percentile for weight. His temperature is 37.7°C (99.8°F), blood pressure is 110/68 mm Hg, pulse is 150/min, and respirations are 50/min. His tongue protrudes beyond the teeth. Neck veins are distended. Crackles are heard at both lung bases. Cardiac examination shows an S3 gallop. The liver is palpated 2 cm below the right costal margin. Neurologic examination shows profound weakness in proximal and distal muscles of the upper and lower extremities. He has 2+ reflexes bilaterally. A chest x-ray shows cardiomegaly. Serum glucose is 105 mg/dL. Which of the following is the enzyme most likely to be defective in this patient?", "answer": "Lysosomal acid maltase", "options": {"A": "Muscle glycogen phosphorylase", "B": "Very-long-chain acyl-CoA dehydrogenase", "C": "Lysosomal acid maltase", "D": "Glycogen debranching enzyme"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["month old boy", "brought", "physician", "2 month history", "fatigue", "weakness", "difficulty feeding", "delivered", "term", "year old woman", "not able to sit upright", "percentile", "height", "percentile", "weight", "temperature", "99", "blood pressure", "68 mm Hg", "pulse", "min", "respirations", "50 min", "tongue", "teeth", "Neck veins", "distended", "Crackles", "heard", "lung bases", "Cardiac examination shows", "S3 gallop", "liver", "palpated 2 cm", "right costal margin", "Neurologic examination shows profound weakness", "proximal", "distal muscles", "upper", "lower extremities", "has", "reflexes", "chest x-ray shows cardiomegaly", "Serum glucose", "mg/dL", "following", "enzyme most likely to", "defective", "patient"]}
{"question": "A 4-year-old boy with acute lymphoblastic leukemia is admitted to the hospital to undergo allogeneic bone marrow transplantation. Two weeks after the conditioning regimen is started, he develops a temperature of 38.5°C (101.3°F). Laboratory studies show:\nHemoglobin 8 g/dL\nLeukocyte count 1400/mm3\nSegmented neutrophils 20%\nEosinophils 0.5%\nLymphocytes 87%\nMonocytes 1%\nPlatelet count 110,000/mm3\nWhich of the following is the most appropriate pharmacotherapy for this patient?\"", "answer": "Granulocyte-macrophage colony-stimulating factor", "options": {"A": "Transforming growth factor-β", "B": "Erythropoietin", "C": "Interleukin-5", "D": "Granulocyte-macrophage colony-stimulating factor"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["4 year old boy", "acute lymphoblastic leukemia", "admitted", "hospital to", "allogeneic bone marrow transplantation", "Two weeks", "conditioning regimen", "started", "temperature", "Laboratory studies show", "Hemoglobin 8 g Leukocyte", "mm3 Segmented", "Eosinophils 0.5", "Lymphocytes", "Monocytes 1", "Platelet count", "following", "most appropriate pharmacotherapy", "patient"]}
{"question": "A 27-year-old female is brought to the emergency department by police when she attacked her date outside of a pizza restaurant. The patient refused to explain her behavior to the police. She seemed to be responding to internal stimuli when being initially interviewed. The patient has a past medical history of depression, anxiety, and obesity. The patient has a known history of medication non-compliance. Her temperature is 99.5°F (37.5°C), pulse is 112/min, blood pressure is 100/70 mmHg, respirations are 18/min, and oxygen saturation is 98% on room air. On physical exam the patient is poorly kempt and has an odd body odor. Inspection of her oropharynx reveals multiple ulcers. Cardiac exam is unrevealing with the exception of a friction rub. Since the incident, the patient has calmed down and is currently resting. She is no longer responding to internal stimuli and is more cooperative. Lab values are obtained and are below.\n\nSerum:\nNa+: 135 mEq/L\nCl-: 100 mEq/L\nK+: 3.9 mEq/L\nHCO3-: 24 mEq/L\nBUN: 20 mg/dL\nGlucose: 70 mg/dL\nCreatinine: 1.7 mg/dL\nCa2+: 10.0 mg/dL\nMg2+: 1.5 mEq/L\n\nHemoglobin: 10 g/dL\nHematocrit: 35%\nReticulocyte count: 4.9%\nPlatelet count: 275,000/mm^3\nLeukocyte count: 5,500/mm^3\n\nWhich of the following is the next best step in management for this patient's underlying condition?", "answer": "ANA and anti-dsDNA levels", "options": {"A": "IM haloperidol", "B": "Clozapine", "C": "Urine toxicology", "D": "ANA and anti-dsDNA levels"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["27 year old female", "brought", "emergency department", "police", "attacked", "date outside", "pizza restaurant", "patient refused to", "behavior", "police", "to", "internal stimuli", "initially interviewed", "patient", "past medical history of depression", "anxiety", "obesity", "patient", "known history", "medication", "temperature", "99", "pulse", "min", "blood pressure", "100 70 mmHg", "respirations", "min", "oxygen saturation", "98", "room air", "physical exam", "patient", "poorly", "odd body odor", "Inspection", "oropharynx reveals multiple ulcers", "Cardiac exam", "exception", "friction rub", "incident", "patient", "calmed", "currently resting", "longer", "internal stimuli", "more cooperative", "Lab values", "obtained", "Serum", "Na", "mEq/L Cl", "100 mEq/L K", "3.9 mEq/L HCO3", "mEq/L", "20 mg/dL Glucose", "70 mg/dL Creatinine", "1.7 mg/dL Ca2", "10 0 mg/dL Mg2", "1.5 mEq/L", "Hemoglobin", "10 g/dL Hematocrit", "35", "Reticulocyte count", "4", "Platelet count", "mm", "Leukocyte count", "5 500 mm", "following", "next best step", "management", "patient's", "condition"]}
{"question": "A 68-year-old man presents to the emergency department because of fever, abdominal pain, and rapidly progressive distension of the abdomen. His appendix was removed for an abscess 3 days ago. The complete blood count showed leukocytosis. Anaerobic culture of the peritoneal fluid needle aspirate showed a gram-negative pathogen. Which of the following, in addition to polymicrobial infection, is the most likely cause of this patient’s condition?", "answer": "Bacteroides fragilis", "options": {"A": "Bacteroides fragilis", "B": "Campylobacter jejuni", "C": "Clostridium perfringens", "D": "Shigella sonnei"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["68 year old man presents", "emergency department", "fever", "abdominal pain", "rapidly progressive distension", "abdomen", "appendix", "removed", "abscess 3 days", "complete blood count showed leukocytosis", "Anaerobic culture", "peritoneal fluid needle aspirate showed", "gram negative pathogen", "following", "polymicrobial infection", "most likely cause", "patients condition"]}
{"question": "A 31-year-old female patient presents with significant swelling and redness of her fingers that is causing her significant pain. Her right knee has also been stiff and slightly swollen for the past 6 weeks. She is overall fatigued and has difficulty moving around but has not sought medical attention until now. On physical examination, the distal interphalangeal joints are swollen, warm, and painful; her nails are pitted and cracked. There are also rough, erythematous skin patches seen over her elbows which have been present for the last few months. She reports that herer father has a similar condition. They both use hydrating creams and topical glucocorticoids with moderate benefit. Which of the following is the most likely diagnosis?", "answer": "Psoriatic arthritis", "options": {"A": "Gout", "B": "Reactive arthritis", "C": "Psoriatic arthritis", "D": "Dermatomyositis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["31 year old female patient presents", "significant swelling", "redness", "fingers", "causing", "significant pain", "right knee", "stiff", "slightly swollen", "past", "weeks", "overall fatigued", "difficulty moving", "not", "medical attention", "now", "physical examination", "distal interphalangeal joints", "swollen", "warm", "painful", "nails", "pitted", "cracked", "rough", "erythematous skin patches seen", "elbows", "present", "months", "reports", "father", "similar condition", "use hydrating creams", "topical glucocorticoids", "moderate benefit", "following", "most likely diagnosis"]}
{"question": "A 44-year-old woman presents to her primary care physician because she has been having fever, chest pain, and cough for the last several weeks. She presented to the physician because she discovered blood in her sputum after coughing. She recently returned from a year of traveling abroad, but has otherwise been healthy. Based on clinical suspicion, an acid fast stain is performed showing the causative organism, and she is started on appropriate therapy. Two weeks later, she returns with a skin rash, diarrhea, and confusion, and is given a factor to take in addition to the medications previously prescribed. Which of the following is a characteristic of the factor that was most likely provided?", "answer": "Required for dehydrogenase enzymes", "options": {"A": "Required for collagen hydroxylation", "B": "Required for dehydrogenase enzymes", "C": "Required for methionine processing", "D": "Required for methylmalonyl-CoA processing"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "primary care physician", "fever", "chest pain", "cough", "weeks", "presented", "physician", "discovered blood", "sputum", "coughing", "recently returned", "year", "traveling abroad", "healthy", "Based", "clinical suspicion", "acid fast stain", "performed showing", "organism", "started", "appropriate therapy", "Two weeks later", "returns", "skin rash", "diarrhea", "confusion", "given", "factor to take in addition to", "medications", "prescribed", "following", "a characteristic", "factor", "most likely provided"]}
{"question": "A 51-year-old Asian woman presents to her primary care provider with abdominal pain. On examination, she is found to have rebound tenderness in the lower right quadrant of her abdomen. Further workup suggests ovarian cancer, which is confirmed later in the week to be stage 4 with confirmed distant metastases in the lungs and brain. Which of the following routes describes the most likely lymphatic route for this malignancy to have metastasized to the brain?", "answer": "Sentinel node - right lumbar trunk - cisterna chyli - thoracic duct - left subclavian vein - systemic circulation", "options": {"A": "Sentinel node - left lumbar trunk - cisterna chyli - right bronchomediastinal trunk - right lymphatic duct - right subclavian vein - systemic circulation", "B": "Sentinel node - left lumbar trunk - cisterna chyli - thoracic duct - left subclavian vein - systemic circulation", "C": "Sentinel node - right lumbar trunk - cisterna chyli - right bronchomediastinal trunk - right lymphatic duct - right subclavian vein - systemic circulation", "D": "Sentinel node - right lumbar trunk - cisterna chyli - thoracic duct - left subclavian vein - systemic circulation"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old Asian woman presents", "primary care provider", "abdominal pain", "examination", "found to", "rebound tenderness", "lower right quadrant of", "abdomen", "Further workup suggests ovarian cancer", "confirmed later", "week to", "stage 4", "confirmed distant metastases", "lungs", "brain", "following routes", "most likely lymphatic route", "malignancy to", "metastasized", "brain"]}
{"question": "A 49-year-old man comes to the physician because of a 1-week history of diarrhea and abdominal bloating. His stools are bulky, foul-smelling, and difficult to flush. Over the past 6 months, he has had recurrent dull epigastric pain that is triggered by meals and lasts for a few days. He drinks 6 to 8 beers daily. Abdominal examination shows mild epigastric tenderness with no rebound or guarding. A CT scan of the abdomen is shown. The structure indicated by the arrows is most likely lined by which of the following?", "answer": "Granulation tissue", "options": {"A": "Simple ductal epithelium", "B": "Granulation tissue", "C": "Pyogenic membrane", "D": "Columnar mucinous epithelium"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "physician", "1-week history", "diarrhea", "abdominal bloating", "stools", "bulky", "smelling", "difficult to flush", "past 6 months", "recurrent dull epigastric", "triggered by meals", "lasts", "days", "drinks 6", "8 beers daily", "Abdominal examination shows mild epigastric tenderness", "guarding", "CT scan", "abdomen", "shown", "structure indicated", "arrows", "most likely lined"]}
{"question": "An 80-year-old African American man is brought to the emergency department in a confused state with history of general illness for the past week. He is known to be hypertensive, but noncompliant with medications for the last 20 years. Physical examination reveals dry skin, ecchymoses, and conjunctival pallor. His blood pressure is 180/99 mm Hg, heart rate is 89/min, and respiratory rate is 17/min. The initial laboratory results are remarkable for hemoglobin of 10 g/dL, mean corpuscular volume of 90 μm3, platelet count of 200,000/mm3, blood urea nitrogen of 29 mg/dL, and creatinine of 2.1 mg/dL. Which of the following would be the best initial management for this patient's condition?", "answer": "Angiotensin-converting-enzyme inhibitor (ACEI)", "options": {"A": "Angiotensin-converting-enzyme inhibitor (ACEI)", "B": "Angiotensin II receptor blocker (ARB)", "C": "Calcium channel blocker (CCB)", "D": "Thiazide"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["80 year old African American man", "brought", "emergency department", "confused state", "history of general illness", "past week", "known to", "hypertensive", "noncompliant", "medications", "last 20 years", "Physical examination reveals dry skin", "ecchymoses", "conjunctival pallor", "blood pressure", "99 mm Hg", "heart rate", "min", "respiratory rate", "min", "initial laboratory results", "hemoglobin", "10 g", "mean corpuscular volume", "90 m3", "platelet count", "200", "mm3", "blood urea nitrogen", "29 mg/dL", "creatinine", "mg/dL", "following", "best initial management", "patient's"]}
{"question": "A 4-month-old boy is brought to the pediatrician by his parents. He presents to the pediatric ward with fever, dyspnea, and cough, which he developed 3 days ago. His mother also reports he had poor weight gain despite a good appetite during the past 2 months as well as frequent stools with an unpleasant smell. He was born at 29 weeks via spontaneous vaginal delivery. He is meeting all of his milestones and is up to date with all vaccines. The child is breastfed exclusively. His blood pressure is 80/50 mm Hg, the heart rate is 109/min, the respiratory rate is 29/min, and the temperature is 39.1°C (102.4°F). The patient’s weight is between the 5th and 10th percentile. His length is between the 50th and 75th percentile. The patient is sluggish and reacts torpidly to examination. His skin is pale and dry with decreased turgor and elasticity. On auscultation, there are diminished vesicular sounds and disseminated moist rales at the bases of both lungs. Heart sounds are normal. The abdomen is distended without palpable masses. The patient’s blood analysis shows the following findings:\nComplete blood count \n Erythrocytes  3.3 x 106/mm3\n Hb  12 g/dL\n Total leukocyte count  17,500/mm3\n Neutrophils\n 59%\n Lymphocytes\n 32%\n Eosinophils\n 3%\n Monocytes\n 6%\n Basophils\n 0\nPlatelet count\n232,000/mm3\nSputum culture grows Pseudomonas aeruginosa. A sweat test shows chloride concentration of 85 mEq/L (elevated). Which of the following is involved in the pathogenesis of this patient’s symptoms?", "answer": "Abnormal CFTR protein", "options": {"A": "Neutrophil elastase damages lung tissue due to lack of alpha-1-antitrypsin.", "B": "Abnormal CFTR protein", "C": "Electron transport chain in mitochondria is disrupted due to lack of glycerol-3-phosphate dehydrogenase.", "D": "Due to mutations in dynein, the ciliary epithelium fails to provide appropriate mucociliary clearance."}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["4 month old boy", "brought", "pediatrician", "parents", "presents", "pediatric ward", "fever", "dyspnea", "cough", "3 days", "mother", "reports", "poor weight gain", "good appetite", "past", "months", "frequent stools", "smell", "born", "29 weeks", "spontaneous vaginal delivery", "meeting", "milestones", "date", "vaccines", "child", "breastfed", "blood pressure", "80 50 mm Hg", "heart rate", "min", "respiratory rate", "29 min", "temperature", "4F", "patients weight", "5th", "percentile", "length", "50th", "percentile", "patient", "sluggish", "reacts", "examination", "skin", "pale", "dry", "decreased turgor", "elasticity", "auscultation", "diminished vesicular sounds", "disseminated moist rales", "the bases of", "lungs", "Heart sounds", "normal", "abdomen", "distended", "palpable masses", "patients blood analysis shows", "following findings", "Complete blood count", "mm3", "12 g", "17 500", "59", "6", "0", "Sputum culture", "Pseudomonas aeruginosa", "sweat test shows chloride concentration", "85 mEq/L", "elevated", "following", "involved", "pathogenesis", "patients"]}
{"question": "A 15-year-old girl is brought to the physician by her mother because of worsening grades over the past year. Since she started high school one year ago, her academic performance has decreased. She also has had difficulty finding friends at the new school. She is afraid that her classmates will make fun of her and think that she is “stupid.” One month ago, when she had to give a presentation, she could not stop wondering how her classmates were going to react if she said something wrong. During the presentation, her heart started racing and she became flushed. Since this event, she avoids saying anything in class. She spends her breaks in the restroom because she is worried that nobody will talk to her. Physical and neurologic examinations show no abnormalities. On mental status examination, the girl avoids eye contact and appears uncomfortable and anxious. Which of the following is the most appropriate pharmacotherapy for this patient's condition?", "answer": "Fluoxetine", "options": {"A": "Clomipramine", "B": "Phenelzine", "C": "Fluoxetine", "D": "Propranolol"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old girl", "brought", "physician", "mother", "worsening grades", "past year", "started high school one year ago", "academic performance", "decreased", "difficulty finding friends", "new school", "afraid", "classmates", "make", "think", "One month", "to give", "presentation", "not stop", "classmates", "to", "wrong", "presentation", "heart started racing", "flushed", "event", "class", "spends", "breaks", "restroom", "worried", "talk", "Physical", "neurologic examinations show", "abnormalities", "mental", "girl", "eye contact", "appears", "anxious", "following", "most appropriate pharmacotherapy", "patient's condition"]}
{"question": "A 3-year-old boy is brought to the clinic by his parents because he ‘hasn’t been himself lately’ and reportedly gets tired very easily from his swimming classes in comparison to the other kids. He also ‘can’t catch his breath’ at times. The mother also reports that he seems to be slightly shorter than other children his age. His temperature is 36.6°C (97.9°F), blood pressure is 110/70 mm Hg, and respiratory rate is 14/min. On auscultation, a localized harsh pansystolic murmur is heard over the left sternal border at the level of the 2nd–3rd intercostal space. The murmur becomes louder when the patient is asked to squat. An echocardiogram is performed. Which of the structures below gives rise to the defective structure that is causing this patient’s symptoms?", "answer": "Endocardial cushion", "options": {"A": "Endocardial cushion", "B": "Infundibular septum", "C": "3rd pharyngeal arch", "D": "Rathke’s pouch"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old boy", "brought", "clinic", "parents", "hasnt", "gets tired very easily", "swimming classes", "kids", "cant catch", "breath", "times", "mother", "reports", "to", "slightly shorter", "children", "age", "temperature", "36", "97 9F", "blood pressure", "70 mm Hg", "respiratory rate", "min", "auscultation", "localized harsh pansystolic murmur", "heard", "left sternal border", "level", "intercostal space", "murmur", "louder", "patient", "to squat", "echocardiogram", "performed", "structures", "gives rise", "defective structure", "causing", "patients symptoms"]}
{"question": "A 26-year-old woman developed rapidly progressive septic shock associated with nuchal rigidity, petechiae, and purpura. She tested positive for both Kernig and Brudzinski's signs and shows signs of confusion, dyspnea, and hypotension. The blood culture results confirmed the presence of Neisseria meningitidis, and a complete blood count (CBC) revealed leukocytosis. Which one of the cytokines below takes part in the pathogenesis of septic shock?", "answer": "Tumor necrosis factor-α", "options": {"A": "Tumor necrosis factor-α", "B": "Interleukin-5", "C": "Interleukin-12", "D": "Interleukin-4"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "rapidly progressive septic shock associated with nuchal rigidity", "petechiae", "purpura", "tested positive", "Brudzinski's signs", "shows signs", "confusion", "dyspnea", "hypotension", "blood culture results confirmed", "presence", "Neisseria meningitidis", "complete blood count", "CBC", "revealed leukocytosis", "one", "cytokines", "takes part", "pathogenesis of septic shock"]}
{"question": "A 35-year-old man comes to the physician because of episodes of difficulty swallowing for the past 3 months. He feels solid food getting stuck in his chest behind the sternum when he eats. Drinking does not cause any difficulty swallowing. He has no coughing or nasal regurgitation. He has no hoarseness or weight loss. He has had heartburn for 2 years with no response to high-dose omeprazole. His past medical history is also significant for asthma and eczema. He takes no medications except for omeprazole. His vital signs are within normal limits. Physical examination shows no abnormal findings. Which of the following best explains these findings?", "answer": "Eosinophilic esophagitis", "options": {"A": "Achalasia", "B": "Diffuse esophageal spasm", "C": "Eosinophilic esophagitis", "D": "Esophageal reflux disease"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["35 year old man", "physician", "of episodes", "difficulty swallowing", "past 3 months", "feels solid food getting", "chest", "sternum", "eats", "Drinking", "not cause", "difficulty swallowing", "coughing", "nasal regurgitation", "hoarseness", "weight loss", "heartburn", "years", "response", "high omeprazole", "past medical history", "significant", "asthma", "eczema", "takes", "medications", "omeprazole", "vital signs", "normal", "Physical examination shows", "abnormal findings", "following best", "findings"]}
{"question": "A 33-year-old man presents to the emergency department with altered mental status. He was at work as a construction worker when his coworkers found him down at the work site. The patient recently underwent anesthesia for an appendectomy several months ago. He also has a past medical history of schizophrenia well controlled with haloperidol and is currently taking phenytoin for epilepsy. He is also currently taking propranolol for anxiety and hyperthyroidism. His temperature is 106°F (41.1°C), blood pressure is 109/62 mmHg, pulse is 170/min, respirations are 23/min, and oxygen saturation is 95% on room air. Physical exam is notable for an altered man with a Glasgow Coma Scale of 10. He has minimal muscle tone and is incoherent when answering questions. The patient is covered in sweat and dirt. Which of the following is the most likely diagnosis?", "answer": "Exertional heat stroke", "options": {"A": "Exertional heat stroke", "B": "Malignant hyperthermia", "C": "Neuroleptic malignant syndrome", "D": "Thyroid storm"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man presents", "emergency department", "altered mental status", "work", "construction worker", "coworkers found", "work site", "patient recently", "anesthesia", "appendectomy", "months", "past medical well controlled", "haloperidol", "currently taking phenytoin", "epilepsy", "currently taking propranolol", "anxiety", "hyperthyroidism", "temperature", "blood pressure", "62 mmHg", "pulse", "min", "respirations", "23 min", "oxygen saturation", "95", "room air", "Physical exam", "notable", "altered man", "Glasgow Coma Scale", "10", "minimal muscle tone", "incoherent", "answering questions", "patient", "covered", "sweat", "dirt", "following", "most likely diagnosis"]}
{"question": "A 67-year-old man is brought to the hospital by his relatives. He complains of early satiety, abdominal discomfort after food intake, and abdominal bloating. These symptoms have been present since the patient was 52, but they were milder at that time so he paid little attention to them since. Tingling and decreased sensation in both lower extremities began a few months ago. His relatives also note that he has become excessively somnolent and forgetful. The patient’s medical history is significant for acute hepatitis B 20 years ago. He smokes a pack of cigarettes per day and drinks alcohol occasionally. His weight is 61 kg (134.5 lb), height is 181 cm (5 ft 11 in), and BMI is 18.6 kg/m2. His vital signs include: blood pressure 110/80 mm Hg, heart rate 89/min, respiratory rate 13/min, and temperature 36.1°C (96.9°F). The patient’s skin is pale, thin, dry, and hypoelastic. Lymph nodes and the thyroid gland are not enlarged. Lung and heart examinations are within normal limits for his age. The patient’s tongue is bright red with atrophic papillae. The abdomen is distended and tender to palpation in the epigastric area. Neurological examination shows symmetrical bilateral distal hypoesthesia for all sensations and decreased muscle strength in both upper and lower extremities. On a mini-mental status examination, the patient scores 25. The patient’s blood test results are as follows:\nErythrocytes 2.8 x 109/mm3\nHb 8.6 g/dL\nHt 37%\nMean corpuscular hemoglobin  49.9 pg/cell (3.1 fmol/cell)\nMean corpuscular volume 142 µm3 (142 fL)\nReticulocyte count 0.3%\nTotal leukocyte count 3,070/mm3\nNeutrophils 54%\nLymphocyte 32%\nEosinophil 3%\nMonocyte 11%\nBasophil 0%\nPlatelet count 195,000/mm3\nHbA1C 4.3%\nFasting plasma glucose 4.6 mmol/l (82.9 mg/dL)\nAspartate aminotransferase 22 U/L\nAlanine aminotransferase 19 U/L\nAmylase 32 U/L\nTotal bilirubin 32 µmol/L (1.87 mg/dL)\nConjugated bilirubin 8 µmol/L (0.4677 mg/L)\nWhich of the following options best explains the patient’s neurological and psychiatric symptoms?", "answer": "Impaired methylation of myelin phospholipids", "options": {"A": "Chronic bilirubin toxicity", "B": "Chronic acetaldehyde influence", "C": "Impaired methylation of myelin phospholipids", "D": "Influence of pseudo-neurotransmitters"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["67 year old man", "brought", "hospital", "relatives", "early satiety", "abdominal discomfort", "food intake", "abdominal bloating", "symptoms", "present", "patient", "milder", "time", "paid little attention", "Tingling", "decreased sensation in", "lower extremities began", "few months", "relatives", "note", "excessively somnolent", "forgetful", "patients medical history", "significant", "acute hepatitis B 20 years", "smokes", "pack", "cigarettes", "day", "drinks alcohol occasionally", "weight", "61 kg", "height", "5 ft", "BMI", "kg/m2", "vital signs include", "blood pressure", "80 mm Hg", "heart rate", "min", "respiratory rate", "min", "temperature 36", "96 9F", "patients skin", "pale", "thin", "dry", "Lymph nodes", "thyroid gland", "not enlarged", "Lung", "heart examinations", "normal limits", "age", "patients tongue", "bright red", "atrophic papillae", "abdomen", "distended", "tender", "palpation", "epigastric area", "Neurological examination shows symmetrical bilateral distal hypoesthesia", "sensations", "decreased muscle strength", "upper", "lower extremities", "mini-mental status examination", "patient scores", "patients blood test results", "follows", "Erythrocytes", "mm3 Hb", "g", "Ht", "Mean corpuscular hemoglobin", "pg/cell", "3.1 fmol cell", "Mean corpuscular volume", "m3", "fL", "Reticulocyte count 0.3", "Total leukocyte count", "mm3", "54", "Lymphocyte 32", "Monocyte", "Basophil", "Platelet count", "4", "Fasting plasma glucose", "mmol/l", "mg/dL", "Aspartate aminotransferase", "U/L Alanine aminotransferase", "Amylase", "bilirubin", "mg/dL", "Conjugated bilirubin", "mol/L", "0", "mg", "following options best", "patients neurological", "psychiatric symptoms"]}
{"question": "A four-day-old neonate is brought to the pediatrician with vaginal discharge for the last two days. Her mother is concerned about the blood-tinged discharge but states that her daughter has been feeding and voiding well. The neonate was delivered at 39 weeks gestation by an uncomplicated vaginal delivery, and she and her mother were discharged home after two days. The prenatal course was complicated by chlamydia in the mother during the first trimester, for which she and the partner were both treated with a negative test of cure. The neonate’s biological father is no longer involved the patient's care, but her mother’s boyfriend has been caring for the baby whenever the mother rests. At this visit, the neonate’s temperature is 98.5°F (36.9°C), pulse is 138/min, and respirations are 51/min. She appears comfortable, and cardiopulmonary and abdominal exams are unremarkable. There are no bruises or marks on her skin. Examination of the genitals reveals no vulvar irritation or skin changes, but there is scant pink mucoid discharge at the introitus. Which of the following is the best next step in management?", "answer": "Reassurance", "options": {"A": "Vaginal exam under anesthesia", "B": "Vaginal culture", "C": "Warm water irrigation of the vagina", "D": "Reassurance"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["four day old neonate", "brought", "pediatrician", "vaginal discharge", "two days", "mother", "concerned", "blood-tinged discharge", "states", "daughter", "feeding", "voiding well", "neonate", "delivered", "weeks gestation", "uncomplicated vaginal", "mother", "discharged home", "two days", "prenatal course", "complicated", "chlamydia", "mother", "first trimester", "partner", "treated with", "negative test", "cure", "neonates biological father", "longer involved", "patient's care", "mothers boyfriend", "caring", "baby", "mother rests", "visit", "neonates temperature", "98", "36", "pulse", "min", "respirations", "min", "appears", "cardiopulmonary", "abdominal exams", "unremarkable", "bruises", "marks", "skin", "Examination of", "genitals reveals", "vulvar irritation", "skin changes", "scant pink mucoid discharge", "introitus", "following", "best next step", "management"]}
{"question": "A 53-year-old male presents to his primary care physician complaining of fatigue and joint and muscle pain. He reports a 6-month history of slowly progressive tiredness associated with dull achy pain in his knees, hips, and shoulders. His past medical history is notable for hypertension, diabetes, and stable angina. He takes lisinopril, metformin, glyburide, and aspirin. He has a history of intravenous drug use and was homeless in his early 30’s. He drinks alcohol socially and has a 30 pack-year smoking history. His temperature is 98.6°F (37°C), blood pressure is 130/85 mmHg, pulse is 95/min, and respirations are 18/min. Physical examination reveals a generally well-appearing male without evidence of ascites, peripheral edema, or jaundice. Results from laboratory tests are below:\n\nHepatitis A IgM: Negative\nHepatitis A IgG: Negative\nHepatitis B surface antigen: Negative\nHepatitis B E antigen: Negative\nHepatitis B core antigen: Negative\nHepatitis B surface IgG: Positive\nHepatitis B E IgG: Negative\nHepatitis B core IgG: Negative\nHepatitis C IgG: Positive\nHCV RNA: 100,000,000 IU/ml\n\nThis patient should be started on which of the following medications?", "answer": "Sofosbuvir and simeprevir", "options": {"A": "Sofosbuvir and simeprevir", "B": "Interferon-gamma", "C": "Ribavirin", "D": "Lamivudine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old male presents", "primary care physician", "fatigue", "joint", "muscle pain", "reports", "month history", "slowly progressive tiredness associated with dull achy pain", "knees", "hips", "shoulders", "past medical history", "notable", "hypertension", "diabetes", "stable angina", "takes lisinopril", "metformin", "glyburide", "aspirin", "history", "intravenous drug use", "homeless", "early 30s", "drinks alcohol", "30 pack-year smoking history", "temperature", "98", "blood pressure", "85 mmHg", "pulse", "95 min", "respirations", "min", "Physical examination reveals", "well appearing male", "evidence", "ascites", "peripheral edema", "jaundice", "Results", "laboratory tests", "Hepatitis A IgM", "Negative Hepatitis A", "Negative Hepatitis B surface antigen", "Negative Hepatitis B E antigen", "Negative Hepatitis B core antigen", "Negative Hepatitis B surface IgG", "Positive Hepatitis", "E", "Negative Hepatitis B core", "Negative Hepatitis C", "Positive HCV RNA", "100", "IU/ml", "patient", "started", "following medications"]}
{"question": "A 40-year-old woman presents to her family physician with a 3-week history of swollen neck. The small, round, and painless swelling, which was detected 3 weeks ago in the middle of her neck, has now increased in size. The swelling is associated with sweaty palms and soles, insomnia, irritability, nervousness, and fatigue; however, the patient does not complain of fever, cervical lymphadenopathy, weight loss, vision problems, or body swelling. The patient’s medical history is negative for similar symptoms or a thyroid disorder. The vital signs are within normal limits. Local examination reveals a 3 x 3 cm round, non-tender, non-fluctuant, and non-pulsatile swelling in the anterior triangle of her neck. The patient carries a total white blood cell count of 10,200/mm3, including 70% neutrophils, 30% lymphocytes, and zero eosinophils.The erythrocyte sedimentation rate is 20 mm/hr (normal, 0–29 mm/hr). What is the most likely diagnosis?", "answer": "Silent thyroiditis", "options": {"A": "Graves' disease", "B": "De Quervain’s thyroiditis", "C": "Silent thyroiditis", "D": "Hashimoto’s thyroiditis"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old woman presents", "family physician", "3 week history", "swollen neck", "small", "round", "painless swelling", "detected 3 weeks", "middle", "neck", "now increased in size", "swelling", "associated with sweaty palms", "soles", "insomnia", "irritability", "nervousness", "fatigue", "patient", "not", "fever", "cervical lymphadenopathy", "weight loss", "vision problems", "body swelling", "patients medical history", "negative", "similar symptoms", "thyroid disorder", "vital signs", "normal limits", "Local examination reveals", "3", "3", "round", "non-tender", "fluctuant", "non-pulsatile swelling", "the anterior triangle of", "neck", "patient carries", "total white blood cell count", "10", "mm3", "including 70", "neutrophils", "30", "lymphocytes", "zero eosinophils", "erythrocyte sedimentation rate", "20 mm", "normal", "mm", "most likely diagnosis"]}
{"question": "A 27-year-old woman with no past medical history presents to the emergency department with recurrent wrist and neck pain for the last 2 months. She reports that her fingers feel stiff in the morning and the symptoms tend to improve as the day progresses. She denies any recent trauma or other inciting events. Family history is significant for a grandmother who suffered from fibromyalgia. Her temperature is 37°C (98.6°F), blood pressure is 120/70 mm Hg, respiratory rate is 16/min, and heart rate is 70/min. On physical examination, her metacarpophalangeal joints are erythematous and tender. Which of the following would be most helpful for diagnosing this patient’s condition?", "answer": "Anti-cyclic citrullinated peptide (anti-CCP) antibody", "options": {"A": "Synovial fluid analysis", "B": "Anti-cyclic citrullinated peptide (anti-CCP) antibody", "C": "Rheumatoid factor", "D": "X-ray of cervical spine"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["27 year old woman", "past medical history presents", "emergency department", "recurrent wrist", "neck pain", "months", "reports", "fingers feel stiff", "morning", "symptoms", "to", "day progresses", "denies", "recent trauma", "events", "Family history", "significant", "grandmother", "suffered", "fibromyalgia", "temperature", "98", "blood pressure", "70 mm Hg", "respiratory rate", "min", "heart rate", "70 min", "physical examination", "metacarpophalangeal joints", "erythematous", "tender", "following", "most helpful", "diagnosing", "patients condition"]}
{"question": "A 66-year-old man comes to the physician because of fatigue and swelling of his legs and feet for 6 weeks. During this time he has felt like his eyes have been unusually puffy in the mornings and his urine has been frothy. He has hypertension and rheumatoid factor-positive rheumatoid arthritis. Current medications include amlodipine, methotrexate, and ibuprofen. He does not smoke. He has a history of chronic alcohol abuse. His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 148/86 mm Hg. Physical examination shows pallor, periorbital edema, 2+ pedal edema, and ascites. He has swan-neck deformities and nodules of multiple fingers and swelling and restricted range of motion of bilateral knee joints. Laboratory studies show:\nHemoglobin 8.2 mg/dl\nProthrombin time 12 seconds\nSerum\nAlbumin 2.8 g/dl\nTotal bilirubin 1.0 mg/dl\nAlkaline phosphatase 120 U/L\nAST 20 U/L\nALT 19 U/L\nUrea 18 mg/dl\nCreatinine 1.2 mg/dl\nUrine\nProtein 3+\nWBCs 5–10/hpf\nRBCs negative\nBacteria negative\nUltrasound of the liver and kidneys shows no abnormalities. Which of the following is the most likely cause of this patient's findings?\"", "answer": "Increased serum amyloid A production", "options": {"A": "Adverse effect of ibuprofen", "B": "Decreased cardiac ejection fraction", "C": "Renal deposition of AL amyloid", "D": "Increased serum amyloid A production"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["66 year old man", "physician", "fatigue", "swelling of", "legs", "feet", "weeks", "time", "felt", "eyes", "puffy", "mornings", "urine", "frothy", "hypertension", "rheumatoid factor-positive rheumatoid arthritis", "Current medications include amlodipine", "methotrexate", "ibuprofen", "not smoke", "history of chronic alcohol abuse", "temperature", "36", "pulse", "80 min", "blood pressure", "mm Hg", "Physical examination shows pallor", "periorbital edema", "2", "pedal edema", "ascites", "swan-neck deformities", "nodules", "multiple fingers", "swelling", "restricted range of motion", "bilateral knee joints", "Laboratory studies show", "Hemoglobin", "Prothrombin time", "Serum", "AST", "ALT", "Urine", "Ultrasound", "liver", "kidneys shows", "abnormalities", "following", "most likely cause", "patient", "indings?"]}
{"question": "A 35-year-old woman presents with an unsteady and broad-based gait, dysmetria, and intention tremor in the distal upper extremities. Her past medical history is relevant for depression, personality changes, and declining work performance, for which she has been put on leave from her current job as an elementary school teacher. On physical examination, patient has dysarthria, dystonia, and an ataxic gait. Ophthalmologic examination reveals multi-colored irises with concentric rings around the periphery (findings shown in the photo). Sensation and motor functions are preserved. Which of the following would you expect to be abnormally accumulated in this patient’s tissues?", "answer": "Copper", "options": {"A": "Iron", "B": "Copper", "C": "Lead", "D": "Mercury"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["35 year old woman presents", "unsteady", "broad-based gait", "dysmetria", "intention tremor", "distal upper extremities", "past medical history", "relevant", "depression", "personality changes", "declining work performance", "put", "leave", "current job", "elementary school teacher", "physical examination", "patient", "dysarthria", "dystonia", "ataxic gait", "Ophthalmologic examination reveals multi colored irises", "concentric rings", "periphery", "findings shown", "Sensation", "motor functions", "preserved", "following", "to", "patients tissues"]}
{"question": "A 6-year-old Russian boy who recently immigrated to the United States presents to your office with fever and dyspnea. On examination of the oropharynx, you note a grayish-white pseudomembrane and uneven elevation of the soft palate. The patient displays marked enlargement of the cervical lymph nodes. Which of the following describes the organism responsible for this patient's disease?", "answer": "Gram-positive bacteria producing exotoxin that acts via ADP ribosylation", "options": {"A": "Yeast with pseudohyphae", "B": "Gram-positive bacteria producing exotoxin that acts via ADP ribosylation", "C": "Gram-positive cocci with hyaluronic acid capsule", "D": "Gram-negative encapsulated bacteria producing IgA protease"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old Russian boy", "recently", "United States presents", "office", "fever", "dyspnea", "examination", "oropharynx", "note", "grayish white pseudomembrane", "elevation", "soft palate", "patient displays marked enlargement of", "cervical lymph nodes", "following", "organism responsible", "patient's disease"]}
{"question": "A 17-year-old male presents to the emergency department after a motor vehicle accident. The patient was an unrestrained driver in a head-on collision. He has a past medical history of asthma, depression, and anxiety. He is not currently taking any medications. His temperature is 99.5°F (37.5°C), blood pressure is 90/60 mmHg, pulse is 115/min, respirations are 22/min, and oxygen saturation is 99% on room air. The patient's cardiopulmonary exam is within normal limits. The patient is breathing on his own and has strong distal pulses. Ultimately, the patient is discharged with follow up instructions after no significant fractures or injuries are found. The patient then presents 4 months later to his primary doctor with weakness. The patient's strength in his upper extremities is 1/5. He has reduced sensation in his upper extremities as well. The patient's lower extremities reveal 5/5 strength with intact sensation. A chest radiograph and basic labs are ordered. Which of the following is the most likely diagnosis?", "answer": "Syringomyelia", "options": {"A": "Cervical spine fracture", "B": "Intracranial hemorrhage", "C": "Syringomyelia", "D": "Conversion disorder"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old male presents", "emergency department", "motor vehicle accident", "patient", "driver", "head", "collision", "past medical", "depression", "anxiety", "not currently taking", "medications", "temperature", "99", "blood pressure", "90 60 mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "99", "room air", "patient's cardiopulmonary exam", "normal limits", "patient", "breathing", "strong distal pulses", "patient", "discharged", "follow up instructions", "significant fractures", "injuries", "found", "patient then presents 4 months later", "primary doctor", "weakness", "patient's strength", "upper extremities", "1/5", "reduced sensation", "upper extremities", "well", "patient's lower extremities reveal 5/5 strength", "intact sensation", "chest radiograph", "basic labs", "ordered", "following", "most likely diagnosis"]}
{"question": "A 62-year-old woman with a history of hypertension and type 2 diabetes mellitus comes to the physician for a routine health maintenance examination. She has smoked 1 pack of cigarettes daily for the last 15 years. Current medications include glyburide and amlodipine. The physician prescribes a medication that decreases the production of mevalonate. Which of the following changes to the serum is most likely to develop as an adverse effect of the prescribed drug?", "answer": "Increased creatine kinase concentration", "options": {"A": "Increased creatine kinase concentration", "B": "Decreased glucose concentration", "C": "Increased triglyceride concentration", "D": "Increased bradykinin concentration"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["62 year old woman", "history of hypertension", "type 2 diabetes mellitus", "physician", "routine health maintenance examination", "smoked 1 pack", "cigarettes daily", "last", "years", "Current medications include glyburide", "amlodipine", "physician", "medication", "decreases", "production", "mevalonate", "following changes", "serum", "most likely to", "adverse effect", "prescribed drug"]}
{"question": "A 21-year-old woman comes to the physician for evaluation of excess hair growth on her face. Menses occur irregularly at 45 to 65-day intervals. She is 159 cm (5 ft 3 in) tall and weighs 59 kg (130 lb); BMI is 23 kg/m2. Physical examination shows facial acne and growth of coarse dark hair on the face, chest, and lower back. Pelvic examination shows no abnormalities. Serum studies show:\nSodium 141 mEq/L\nPotassium 4.2 mEq/L\nGlucose 109 mg/dL\nCortisol (1600 h) 4 μg/dL\nProlactin 14 ng/mL\n17-hydroxyprogesterone 390 ng/dL (N=20–300 ng/dL)\nTestosterone 91 ng/dL (N=8–60 ng/dL)\nA urine pregnancy test is negative. This patient's condition is most likely associated with which of the following?\"", "answer": "Hyperplasia of the adrenal cortex", "options": {"A": "Hyperproliferation of theca interna cells", "B": "Exogenous anabolic steroid use", "C": "Ovarian fibrosis and multiple cystic follicles", "D": "Hyperplasia of the adrenal cortex"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["21-year-old woman", "physician", "evaluation of excess hair growth", "face", "Menses occur", "65 day intervals", "5 ft", "tall", "59 kg", "BMI", "23 kg/m2", "Physical examination shows facial acne", "growth", "coarse dark hair", "face", "chest", "lower back", "Pelvic examination shows", "abnormalities", "Serum studies show", "Sodium", "mEq/L Potassium", "Glucose", "mg/dL Cortisol", "1600 h", "g dL Prolactin 14 ng/mL", "hydroxyprogesterone", "dL", "N", "ng/dL", "Testosterone", "ng/dL", "N", "ng/dL", "urine pregnancy test", "negative", "patient", "ondition ", "ost  ikely  ssociated with "]}
{"question": "A 64-year-old man with coronary artery disease and hypertension comes to the physician for a follow-up examination. His blood pressure ranged from 160/100 mm Hg to 150/94 mm Hg on his previous 3 visits over the past 4 months. Current medications include aspirin, atorvastatin, hydrochlorothiazide, and metoprolol. Three weeks ago, he was also started on amlodipine. His blood pressure today is 158/98 mm Hg. Physical examination shows no other abnormalities. Renal duplex ultrasonography shows 90% occlusion of the right renal artery. Decreased renal blood flow is most likely to cause which of the following?", "answer": "Hyperplasia of juxtaglomerular cells", "options": {"A": "Hyperplasia of juxtaglomerular cells", "B": "Dilation of efferent arteriole", "C": "Decreased prostaglandin synthesis by macula densa", "D": "Decreased reabsorption of bicarbonate at proximal tubule"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["64 year old man", "coronary artery disease", "hypertension", "physician", "follow-up examination", "blood pressure ranged", "100 mm Hg", "mm Hg", "previous", "visits", "past", "months", "Current medications include aspirin", "atorvastatin", "hydrochlorothiazide", "metoprolol", "Three weeks", "started", "amlodipine", "blood pressure today", "98 mm Hg", "Physical examination shows", "abnormalities", "Renal duplex ultrasonography shows 90", "occlusion of", "right renal artery", "Decreased", "blood flow", "most likely to cause", "following"]}
{"question": "A 65-year-old woman is brought to the emergency department by her husband after he found her with nausea, headache, and agitation 1 hour ago. When he left their lakeside cabin 6 hours before to go ice fishing and get more firewood, she did not have any symptoms. She has chronic migraines, hypertension, and type 2 diabetes mellitus. Her medications include lisinopril and metformin, but she ran out of her anti-hypertensive medications over the weekend. Her temperature is 37.1°C (98.8°F), pulse is 110/min, respirations are 21/min, and blood pressure is 154/92 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. She is confused and oriented only to person and place. She recalls only one of three objects after 5 minutes. Her gait is unsteady. Physical examination shows no abnormalities. Which of the following is the most effective intervention for this patient's current condition?", "answer": "Hyperbaric oxygen therapy", "options": {"A": "Intravenous nitroprusside", "B": "Hyperbaric oxygen therapy", "C": "100% oxygen therapy", "D": "Heliox therapy"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["65 year old woman", "brought", "emergency department", "husband", "found", "nausea", "headache", "agitation", "hour", "left", "hours", "to go ice fishing", "more", "not", "symptoms", "chronic migraines", "hypertension", "type 2 diabetes mellitus", "medications include lisinopril", "metformin", "ran out", "anti-hypertensive medications", "weekend", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "98", "confused", "oriented only", "person", "place", "recalls only one", "three objects", "5 minutes", "gait", "unsteady", "Physical examination shows", "abnormalities", "following", "most effective intervention", "patient's current condition"]}
{"question": "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?", "answer": "Right main", "options": {"A": "Left circumflex", "B": "Diagonal perforators", "C": "Septal perforators", "D": "Right main"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["62 year old Caucasian male presents", "emergency room", "severe substernal chest pain", "diaphoresis", "nausea", "Imaging reveals transmural myocardial infarction", "posterior", "of", "ventricular septum", "patient's", "most likely occluded"]}
{"question": "A previously healthy, 24-year-old man comes to the physician because of a 6-week history of loose, nonbloody stools. He also reports abdominal pain, intermittent nausea, and fever. He has not had vomiting, tenesmus, or rectal pain. His vital signs are within normal limits. Abdominal examination reveals tenderness of the right lower abdomen without rebound tenderness. Rectal exam is unremarkable. Laboratory studies show a leukocyte count of 14,800/mm3 and an erythrocyte sedimentation rate of 51 mm/h. Test of the stool for occult blood and stool studies for infection are negative. A CT scan of the abdomen shows mural thickening and surrounding fat stranding of discrete regions of the terminal ileum and transverse colon. A colonoscopy is performed and biopsy specimens of the affected areas of the colon are taken. Which of the following findings is most specific for this patient's condition?", "answer": "Formation of noncaseating granulomas", "options": {"A": "Neutrophilic inflammation of the crypts", "B": "Neutrophil-rich pseudomembranes", "C": "Formation of noncaseating granulomas", "D": "Presence of pseudopolyps"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["healthy", "year old man", "physician", "week history", "loose", "stools", "reports abdominal pain", "intermittent nausea", "fever", "not", "vomiting", "tenesmus", "rectal pain", "vital signs", "normal limits", "Abdominal examination reveals tenderness", "right lower abdomen", "rebound tenderness", "Rectal exam", "unremarkable", "Laboratory studies show", "leukocyte count", "14 800 mm3", "erythrocyte sedimentation rate", "mm/h", "Test", "stool", "occult blood", "stool studies", "infection", "negative", "CT scan", "abdomen shows mural thickening", "surrounding fat stranding of discrete regions", "terminal ileum", "transverse colon", "colonoscopy", "performed", "biopsy specimens of", "affected areas", "colon", "taken", "following findings", "most specific", "patient's condition"]}
{"question": "A 65-year-old man presents with pain in his left thigh for a week. He describes the pain as dull and constant, boring in nature, and localized deep below the thigh muscle. He says it is worse at night. Physical examination is significant for tenderness and warmth over the anterior aspect of the left thigh. A plain radiograph of the left femur shows increased cortical thickness with widened intercortical space. Laboratory studies show:\nAlkaline phosphatase\n925 U/L\nSerum calcium\n9.2 mg/dL\nSerum phosphorus 4.4 mg/dL\nFindings on bone biopsy are shown in the image. Which of the following is the most likely diagnosis in this patient?", "answer": "Osteitis deformans", "options": {"A": "Ewing's sarcoma", "B": "Osteitis deformans", "C": "Osteochondritis dissecans", "D": "Osteitis fibrosa cystica"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["65 year old man presents", "pain", "left thigh", "week", "pain", "dull", "constant", "boring", "nature", "localized deep", "thigh muscle", "worse", "night", "Physical examination", "significant", "tenderness", "warmth", "anterior aspect of", "left thigh", "plain radiograph of", "left femur shows increased cortical thickness", "widened", "space", "Laboratory studies show", "Alkaline phosphatase", "U/L Serum calcium 9", "mg", "phosphorus", "Findings", "bone biopsy", "shown", "image", "following", "most likely diagnosis", "patient"]}
{"question": "A 15-year-old boy is brought to the emergency department because of severe abdominal pain and vomiting for 8 hours. He has had around 3–4 episodes of greenish colored vomit during this period. He has major depressive disorder with psychosis. His mother has Graves' disease. Current medications include sertraline and haloperidol. He appears uncomfortable. His temperature is 37.3°C (99.1°F), pulse is 87/min, and blood pressure is 118/72 mm Hg. He is diagnosed with acute appendicitis and is taken to the operating room for an emergency laparoscopic appendectomy. The appendix is gangrenous and perforated with purulent fluid in the pelvis. Just after the appendiceal base is ligated, the patient shows muscle rigidity and profuse diaphoresis. His temperature is 39.1°C (102.4°F), pulse is 130/min, and blood pressure is 146/70 mm Hg. The pupils are equal and reactive to light. The end-tidal CO2 is 85 mm Hg. Which of the following is the most appropriate treatment for this patient's condition?", "answer": "Dantrolene", "options": {"A": "Dantrolene", "B": "Bromocriptine", "C": "Cyproheptadine", "D": "Surgical embolectomy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy", "brought", "emergency department", "severe abdominal", "vomiting", "8 hours", "episodes of", "colored vomit", "period", "major depressive disorder", "psychosis", "mother", "Graves", "disease", "Current medications include sertraline", "haloperidol", "appears", "temperature", "3C", "99", "pulse", "87 min", "blood pressure", "72 mm Hg", "diagnosed", "acute appendicitis", "taken", "operating room", "emergency laparoscopic", "appendix", "gangrenous", "perforated", "purulent fluid", "pelvis", "appendiceal base", "patient shows muscle rigidity", "diaphoresis", "temperature", "4F", "pulse", "min", "blood pressure", "70 mm Hg", "pupils", "equal", "reactive to light", "end", "CO2", "85 mm Hg", "following", "most appropriate treatment", "patient's condition"]}
{"question": "After a T cell progenitor leaves the bone marrow, most of its development takes place in the thymus. It passes through several stages during its maturation. Positive selection is an important process during maturation of T lymphocytes, and it ensures the preservation of self-major histocompatibility complex (MHC)-restricted T cells. During which of the following developmental stages does a T cell undergo this process?", "answer": "Double-positive T cell", "options": {"A": "Pre-T cell", "B": "Double-positive T cell", "C": "Single-positive CD4+ T cell", "D": "Single-positive CD8+ T cell"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["a T cell progenitor leaves", "bone marrow", "most", "development takes place", "thymus", "passes", "stages", "maturation", "Positive selection", "important process", "maturation", "T lymphocytes", "ensures", "preservation", "self major histocompatibility complex", "restricted T cells", "following developmental stages", "a T", "process"]}
{"question": "A 28-year-old male presents with a recent onset of upsetting dreams, anxiety, and disturbing flashbacks. The patient reports that he returned from active duty in Iraq 3 months ago and was adjusting to life back at home until about 7 weeks ago when he began having intense fear of loud noises and seeing sudden flashbacks to bombing attacks he endured during his time in Iraq. He had to take a leave from his army instructor duties as he was not able to handle the familiar settings of practice shooting ranges and sudden loud explosions during battalion training. After refusing to leave his house, he was finally persuaded by his wife to visit your clinic. What is the most likely diagnosis?", "answer": "Posttraumatic stress disorder", "options": {"A": "Acute stress disorder", "B": "Performance anxiety", "C": "Posttraumatic stress disorder", "D": "Panic attack"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old male presents", "recent onset", "upsetting dreams", "anxiety", "flashbacks", "patient reports", "returned", "active duty", "Iraq", "months", "life back", "home", "about", "weeks", "began", "intense fear", "loud noises", "seeing sudden flashbacks", "bombing attacks", "time", "Iraq", "to take", "leave", "army instructor", "not able to handle", "familiar settings", "practice shooting ranges", "sudden loud explosions", "training", "refusing to leave", "house", "wife to visit", "clinic", "most likely diagnosis"]}
{"question": "A patient with a1-antitrypsin deficiency is warned by his physician that his increasing dyspnea may be worsened by his continued cigarette smoking. Which of the following factors, released by both neutrophils and alveolar macrophages, is responsible for the patient's condition?", "answer": "Elastase", "options": {"A": "Major Basic Protein", "B": "Mucus", "C": "Surfactant", "D": "Elastase"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["patient", "a1 antitrypsin deficiency", "warned", "physician", "increasing dyspnea", "worsened", "continued cigarette smoking", "following factors", "released", "neutrophils", "alveolar macrophages", "responsible", "patient's condition"]}
{"question": "A 54-year-old man comes to the physician for a routine health maintenance examination. He was diagnosed with type 2 diabetes mellitus 1 year ago. His only medication is metformin. His serum glucose is 186 mg/dL and his hemoglobin A1c is 7.6%. The physician prescribes an additional antidiabetic drug and counsels the patient on its delayed onset of action. At a follow-up appointment 4 weeks later, the patient reports that his home blood glucose readings have improved. He also mentions that he has had a weight gain of 4 kg (8.8 lb). The patient has most likely been treated with which of the following drugs?", "answer": "Rosiglitazone", "options": {"A": "Empagliflozin", "B": "Liraglutide", "C": "Rosiglitazone", "D": "Glyburide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["54 year old man", "physician", "routine health maintenance examination", "diagnosed", "type year", "only medication", "metformin", "serum glucose", "mg/dL", "hemoglobin A1c", "physician", "additional antidiabetic drug", "counsels", "patient", "delayed onset of action", "follow-up appointment", "weeks later", "patient reports", "home blood glucose readings", "improved", "weight gain", "kg", "8.8", "patient", "most likely", "treated with", "following drugs"]}
{"question": "A 19-year-old woman is brought into the emergency department after collapsing during a cheerleading practice session. Her vitals taken by the emergency medical services (EMS) include blood pressure 88/55 mm Hg, pulse 55/min. She was given a liter of isotonic fluid while en route to the hospital. At the emergency department, she is alert and oriented and is noted to be anorexic. The patient fervently denies being underweight claiming that she is ‘a fatty’ and goes on to refuse any further intravenous fluid and later, even the hospital meals. Which of the following is the best option for long-term management of this patient’s condition?", "answer": "Cognitive-behavioral therapy", "options": {"A": "Cognitive-behavioral therapy", "B": "In-patient psychiatric therapy", "C": "Antidepressants", "D": "Appetite stimulants"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "brought", "emergency department", "collapsing", "cheerleading practice session", "taken", "emergency medical services", "include blood pressure 88 55 mm Hg", "pulse 55 min", "given", "liter", "fluid", "en route", "hospital", "emergency department", "alert", "oriented", "noted to", "anorexic", "patient", "denies", "underweight", "goes", "refuse", "further intravenous fluid", "later", "hospital meals", "following", "best option", "long-term management", "patients condition"]}
{"question": "A 45-year-old man comes to the physician for a routine health maintenance examination. He was diagnosed with HIV 15 years ago. He was taking triple antiretroviral therapy but stopped a few months ago because he was feeling well. He lives in Wyoming. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. His CD4+ T-lymphocyte count is 47/mm3 (N ≥ 500). The patient currently refuses to restart antiretroviral therapy. Which of the following medication regimens is most appropriate at this time?", "answer": "Trimethoprim, sulfamethoxazole, azithromycin", "options": {"A": "Azithromycin and itraconazole", "B": "Azithromycin and amphotericin B", "C": "Trimethoprim, sulfamethoxazole, azithromycin", "D": "Dapsone, pyrimethamine, itraconazole, azithromycin"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "routine health maintenance examination", "diagnosed", "HIV", "years", "triple antiretroviral therapy", "stopped", "few months", "feeling well", "lives", "Wyoming", "Vital signs", "normal limits", "Cardiopulmonary examination shows", "abnormalities", "CD4", "lymphocyte count", "mm3", "N", "500", "patient currently refuses to restart antiretroviral therapy", "following medication regimens", "most appropriate", "time"]}
{"question": "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?", "answer": "Is transmitted by air conditioning", "options": {"A": "Can form an endospore", "B": "Has no cell wall", "C": "Is more common in parrot owners", "D": "Is transmitted by air conditioning"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old male presents", "emergency department", "fever", "diarrhea", "normal state of health", "2 weeks", "vacation", "trip", "kayaking", "visited spas", "local animals", "ate local foods", "Since returning", "3-day history", "fever", "cough", "headache", "diarrhea", "drinks", "pack-year history of smoking", "presentation", "temperature", "blood pressure", "62 mmHg", "pulse", "min", "respirations", "min", "O2 saturation", "room", "Chest reveals fine crackles", "auscultation", "Chest radiograph reveals patchy infiltrates", "lungs", "labs reveal mild hyponatremia", "mild elevation", "AST/ALT levels", "organism", "most likely responsible", "patient's symptoms", "associated with", "following characteristics"]}
{"question": "A 14-year-old boy presents to the emergency department with hand pain after falling from his skateboard one day ago. He reports that he lost his balance while attempting a new trick and fell on his outstretched hands. He has been icing his hand and taking several tablets of ibuprofen every few hours, but the pain and swelling have not improved. The patient reports that he has not been able to use the hand to take notes in school. His past medical history is significant for infectious mononucleosis last year and type 1 diabetes mellitus for which he has an insulin pump. On physical exam, there is mild swelling over the dorsal aspect of the hand and wrist. He has tenderness in the region between the extensor pollicus longus and the extensor pollicus brevis of the right hand.\n\nWhich of the following is the best next step in management?", "answer": "Radiograph of the wrist", "options": {"A": "Radiograph of the wrist", "B": "MRI of the wrist", "C": "Thumb spica cast", "D": "Radial gutter cast"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old boy presents", "emergency department", "hand pain", "falling", "skateboard one day", "reports", "lost", "balance", "attempting", "new", "fell", "hands", "icing", "hand", "taking", "tablets", "ibuprofen", "few hours", "pain", "swelling", "not improved", "patient reports", "not", "able to use", "hand to take notes in school", "past medical history", "significant", "infectious mononucleosis", "year", "type 1 diabetes mellitus", "insulin pump", "physical exam", "mild swelling", "dorsal aspect of", "hand", "wrist", "tenderness", "region", "extensor", "extensor", "right hand", "following", "best next step", "management"]}
{"question": "A 22-year-old woman comes to the physician for the evaluation of irregular menstrual bleeding. Menses have occurred at 45- to 90-day intervals since menarche at the age of 15 years. Her last menstrual period was 5 weeks ago. The patient reports that she was too embarrassed to discuss this issue with anyone until now. Over the past two years, she was unable to become pregnant despite having unprotected sexual intercourse with her husband on a regular basis. There is no personal or family history of serious illness. She is 170 cm (5 ft 7 in) tall and weighs 85 kg (187 lb); BMI is 29.4 kg/m2. Her vital signs are within normal limits. Examination shows oily skin and severe facial acne. There is abnormal pigmented hair on the upper lip and around both nipples. The patient wishes to have children. In addition to recommending lifestyle modifications, which of the following is the most appropriate step in management?", "answer": "Clomiphene therapy", "options": {"A": "In vitro fertilization with patient's egg", "B": "Progesterone therapy", "C": "Clomiphene therapy", "D": "Leuprolide therapy"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "evaluation", "irregular menstrual bleeding", "Menses", "occurred", "90 day intervals", "menarche at", "age", "years", "last menstrual period", "5 weeks", "patient reports", "embarrassed to discuss", "issue", "now", "past two years", "unable to", "pregnant", "unprotected sexual intercourse", "husband", "regular basis", "personal", "family history", "serious illness", "5 ft", "tall", "85 kg", "BMI", "29", "kg/m2", "vital signs", "normal limits", "Examination shows oily skin", "severe facial acne", "abnormal hair", "upper", "nipples", "patient wishes to", "children", "recommending lifestyle modifications", "following", "most appropriate step", "management"]}
{"question": "A 56-year-old man comes to the emergency department because of nausea and shortness of breath that started while he was at work one hour ago. He also reports lightheadedness that started earlier in the day. He has type 2 diabetes mellitus, for which he takes metformin and sitagliptin. He has smoked 1 pack of cigarettes daily for 20 years. He appears pale and diaphoretic. A 12-lead ECG is shown. Which of the following is the most likely underlying cause of this patient's symptoms?", "answer": "Acute inferior myocardial infarction", "options": {"A": "Viral myocarditis", "B": "Acute pericarditis", "C": "Acute inferior myocardial infarction", "D": "Saddle pulmonary embolus"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "emergency department", "nausea", "shortness of breath", "started", "work one hour", "reports lightheadedness", "started earlier", "day", "type 2 diabetes mellitus", "takes metformin", "sitagliptin", "smoked 1 pack", "cigarettes daily", "20 years", "appears pale", "diaphoretic", "12-lead ECG", "shown", "following", "most likely underlying cause", "patient's symptoms"]}
{"question": "A 27-year-old man with a history of cocaine abuse comes to the physician 2 weeks after undergoing successful arthroscopic repair of a torn medial collateral ligament in his left knee. There were no complications. He was discharged with prescriptions for oxycodone and acetaminophen. He complains of severe pain that prevents him from participating in physical therapy and wakes him from sleep. Physical examination of the left knee shows a healing incision; there is no joint effusion, erythema, or evidence of wound dehiscence, and his gait is normal. When the physician recommends switching to ibuprofen for pain, he becomes visibly angry and demands a refill of oxycodone. Which of the following is the most appropriate response to this patient's request?", "answer": "Request further information about which drugs he has taken recently and in the past", "options": {"A": "Prescribe a long-acting opioid for better pain relief if he is willing to sign a pain contract", "B": "Request further information about which drugs he has taken recently and in the past", "C": "Request consent for urine test to assess current drug use", "D": "Refer to a substance use counselor for addiction counseling"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["27 year old man", "history of cocaine abuse", "physician 2 weeks", "successful arthroscopic repair of", "torn medial collateral ligament", "left knee", "complications", "discharged", "prescriptions", "oxycodone", "acetaminophen", "severe pain", "prevents", "participating", "physical therapy", "wakes", "sleep", "Physical examination", "left knee shows", "healing incision", "joint effusion", "erythema", "evidence of wound dehiscence", "gait", "normal", "physician recommends switching", "ibuprofen", "pain", "angry", "demands", "refill", "oxycodone", "following", "most appropriate response", "patient's request"]}
{"question": "An 89-year-old woman sees her neurologist for a follow-up evaluation. Three months ago, she presented with complaints about facial asymmetry. Her daughter has noticed that her mother’s mouth is droops downwards on the right side of her face and that she cannot close her right eye well. The same side also lacks wrinkles on the forehead. Since then, the patient feels like her facial muscles have gotten weaker. She was given a course of corticosteroids, but she has still not recovered fully. Upon being asked to close her eyes, the patient has difficulty doing so and fails to completely close her eyelids. On examination, there is no loss of pain, temperature, or crude or tactile touch sensations in the whole face. The neurological exam is otherwise unremarkable. This patient also has type 2 diabetes mellitus which is well controlled with metformin. The neurologist recommends a therapy that will help relieve her symptoms. Which of the following is the most likely treatment option being prescribed to this patient?", "answer": "Botox", "options": {"A": "Botox", "B": "Carbamazepine", "C": "Methylprednisolone", "D": "Ceftriaxone"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman sees", "neurologist", "follow-up evaluation", "Three months", "presented", "complaints", "facial asymmetry", "daughter", "mothers mouth", "downwards", "right side of", "face", "close", "right eye well", "same side", "lacks wrinkles", "forehead", "then", "patient feels", "facial muscles", "gotten weaker", "given", "course", "corticosteroids", "not recovered", "to close", "eyes", "patient", "difficulty", "fails to completely close", "eyelids", "examination", "loss", "pain", "temperature", "tactile touch", "whole face", "neurological exam", "unremarkable", "patient", "type 2 diabetes mellitus", "well controlled", "metformin", "neurologist recommends", "therapy", "help relieve", "symptoms", "following", "most likely treatment option", "prescribed", "patient"]}
{"question": "A 28-year-old man is brought to the emergency department because of a 3-day history of fever, chills, and generalized weakness. He has no cough. He was treated for a neck abscess 6 months ago. He takes no medications. He has smoked one pack of cigarettes daily for 10 years and drinks two to three beers daily. He has been using intravenous cocaine and heroin for 6 years. He appears ill. His temperature is 38.6°C (101.5°F), pulse is 112/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Examination shows track marks on both cubital fossae. There are retinal hemorrhages with pale centers. The lungs are clear to auscultation. A grade 3/6 holosystolic murmur is heard best at the lower left sternal border. Laboratory studies show:\nHemoglobin 13.3 g/dL\nLeukocyte count 14,300/mm3\nPlatelet count 278,000/mm3\nSerum\nGlucose 96 mg/dL\nCreatinine 1.0 mg/dL\nTotal bilirubin 0.4 mg/dL\nAST 18 U/L\nALT 22 U/L\nTransthoracic echocardiography shows multiple vegetations on the tricuspid valve and moderate tricuspid regurgitation. Two sets of blood cultures are collected. Which of the following is the most appropriate next step in management?\"", "answer": "Intravenous vancomycin therapy", "options": {"A": "Transesophageal echocardiography", "B": "Intravenous vancomycin therapy", "C": "X-ray of the chest", "D": "CT pulmonary angiogram"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "emergency department", "3-day history", "fever", "chills", "generalized weakness", "cough", "treated", "neck abscess", "months", "takes", "medications", "smoked one pack", "cigarettes daily", "10 years", "drinks two", "three beers daily", "using intravenous cocaine", "heroin", "years", "appears ill", "temperature", "pulse", "min", "respirations", "20 min", "blood pressure", "70 mm Hg", "Examination shows track marks", "cubital fossae", "retinal hemorrhages", "pale centers", "lungs", "clear", "auscultation", "grade", "6 holosystolic murmur", "heard best", "lower left sternal border", "Laboratory studies show", "Hemoglobin", "Leukocyte", "mm3 Platelet count", "Serum", "Creatinine", "18", "L", "Transthoracic echocardiography shows multiple vegetations", "tricuspid valve", "moderate tricuspid regurgitation", "Two sets of blood cultures", "collected", "following", "most appropriate next step", "management"]}
{"question": "A 24-year-old woman comes to the physician because of persistent fatigue for the past 4 months. She has no history of major medical illness. Her temperature is 36°C (96.8°F), pulse is 121/min, and blood pressure is 120/78 mm Hg. Physical examination shows pale conjunctivae. A peripheral blood smear is shown. Which of the following is the most likely cause of this patient's symptoms?", "answer": "Iron deficiency", "options": {"A": "Hereditary spherocytosis", "B": "Vitamin B12 deficiency", "C": "Iron deficiency", "D": "β-thalassemia minor"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "of persistent fatigue", "past", "months", "history of major medical illness", "temperature", "96", "pulse", "min", "blood pressure", "mm Hg", "Physical examination shows pale conjunctivae", "peripheral blood smear", "shown", "following", "most likely cause", "patient's symptoms"]}
{"question": "A 40-year old man presents to the clinic with vague upper abdominal pain that has been worsening for the last several days. He says that he often gets similar pain but less severe and that it worsens with meals. The pain sometimes radiates to his back. He recently lost 15 kg (33.6 lb) of weight secondary to his lack of appetite since his last visit 2 months ago. He admits to drinking alcohol almost every night since the age of 17. His temperature is 37.0° C (98.6°F), respirations are 15/min, pulse is 67/min, and blood pressure is 122/98 mm Hg. Physical examination reveals moderate epigastric tenderness. An abdominal CT scan reveals calcifications as shown by the white arrows. Which of the following organs is affected in this patient?", "answer": "Pancreas", "options": {"A": "Pancreas", "B": "Jejunum", "C": "Duodenum", "D": "Gall bladder"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["40 year old man presents", "clinic", "vague upper abdominal pain", "worsening", "days", "often gets similar pain", "less severe", "worsens", "meals", "pain sometimes radiates", "back", "recently lost", "kg", "weight secondary to", "lack of appetite", "last visit", "months", "admits", "drinking alcohol almost", "night", "age", "temperature", "0", "98", "respirations", "min", "pulse", "67 min", "blood pressure", "98 mm Hg", "Physical examination reveals moderate epigastric tenderness", "abdominal CT reveals calcifications", "shown", "white arrows", "following organs", "affected", "patient"]}
{"question": "A 36-year-old man presents to his physician for a regular checkup, and he expresses an intent to quit smoking. He is a financial director with a 15-pack-year history of smoking who tried quitting several times. He tried different nicotine replacement products, none of which helped him. The patient has gastrointestinal reflux disease and takes omeprazole. The medical history is significant for a head trauma after which he had two seizure episodes. He does not have a history of any other disorders. Currently, he is not on any antiepileptic medication. He heard from his friend about an antidepressant that efficiently helps with smoking cessation. He would like to try this medication, and asks his physician for an advice. Which of the following statements regarding the use of the mentioned medication is correct?", "answer": "Bupropion lowers the seizure threshold and it should not be taken by patients with a history of seizure disorder.", "options": {"A": "Omeprazole interferes with bupropion metabolism and should be taken one hour prior to omeprazole consumption.", "B": "Bupropion is only effective when used together with nicotine replacement products.", "C": "Bupropion lowers the seizure threshold and it should not be taken by patients with a history of seizure disorder.", "D": "The physician may prescribe bupropion for this patient only after a full cardiac workup is performed."}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["36 year old man presents", "physician", "regular checkup", "intent to quit smoking", "financial", "pack-year history of smoking", "quitting several times", "different nicotine replacement products", "helped", "patient", "gastrointestinal disease", "takes omeprazole", "medical history", "significant", "head trauma", "two seizure episodes", "not", "history", "disorders", "Currently", "not", "antiepileptic medication", "heard", "friend", "antidepressant", "helps", "smoking cessation", "to", "medication", "physician", "advice", "following statements", "use", "medication", "correct"]}
{"question": "A 32-year-old woman, gravida 2, para 0, at 22 weeks' gestation comes to the emergency department for abdominal pain and heavy vaginal bleeding for 2 hours. She has had no prenatal care. Her temperature is 37.2°C (99.0°F), pulse is 102/min, respirations are 16/min, and blood pressure is 138/82 mm Hg. The abdomen is nontender, and regular contractions are felt every 2 minutes. The uterus is consistent in size with a 20-week gestation. There is blood on the vulva, introitus, and medial aspect of the thighs. Ultrasound shows complete detachment of the placenta from the uterus. Fetal heart tones are absent. An emergent cesarean delivery is performed. Following the procedure, the patient becomes tearful and distraught. Which of the following is the most appropriate initial response by the physician?", "answer": "“I'm sorry for your loss. This must be a difficult situation for you.”", "options": {"A": "“I'm sorry for your loss. This must be a difficult situation for you.”", "B": "“Losing a baby is difficult, but I'm sure next time it'll work out.”", "C": "“Losing a baby is difficult; but I see this every day, and I know you'll get through it.”", "D": "“I'm sorry for your loss. I can write you a prescription to help with your anxiety and grief.”"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "gravida 2", "para 0", "weeks", "gestation", "emergency department", "abdominal pain", "heavy vaginal bleeding", "hours", "prenatal care", "temperature", "99", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "abdomen", "nontender", "regular contractions", "felt", "2 minutes", "uterus", "consistent", "size", "20 week gestation", "blood", "vulva", "introitus", "medial aspect of", "thighs", "Ultrasound shows complete detachment of", "placenta", "uterus", "Fetal heart tones", "absent", "emergent cesarean delivery", "performed", "Following", "procedure", "patient", "tearful", "following", "most appropriate initial response", "physician"]}
{"question": "A 78-year-old man comes to the physician because of progressively worsening fatigue and headache for 6 months and occasional abdominal pain. He has not had any changes in his weight. He has a history of hypertension, type 2 diabetes mellitus, and chronic shoulder pain. Current daily medications include hydrochlorothiazide, metformin, and ibuprofen. He does not drink alcohol and does not smoke. His diet has mostly consisted of potatoes and lean meats since his wife passed away 1 year ago. His pulse is 92/min and blood pressure is 135/80 mm Hg. Examination shows conjunctival and mucosal pallor. Abdominal and rectal examination shows no abnormalities. Neurological exam shows mild postural tremor. Peripheral blood smear shows red blood cells with increased zones of central pallor and anisocytosis. Which of the following is the most likely underlying cause of this patient’s symptoms?", "answer": "Iron deficiency", "options": {"A": "Folic acid deficiency", "B": "Intravascular hemolysis", "C": "Impaired erythropoietin production", "D": "Iron deficiency"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man", "physician", "worsening fatigue", "headache", "months", "occasional abdominal pain", "not", "changes in", "weight", "history of hypertension", "type 2 diabetes mellitus", "chronic shoulder pain", "Current daily medications include hydrochlorothiazide", "metformin", "ibuprofen", "not drink alcohol", "not smoke", "diet", "mostly consisted", "potatoes", "meats", "wife passed", "year", "pulse", "min", "blood pressure", "80 mm Hg", "Examination shows conjunctival", "mucosal pallor", "Abdominal", "rectal examination shows", "abnormalities", "Neurological exam shows mild postural", "Peripheral blood smear shows red blood cells", "increased zones of central pallor", "anisocytosis", "following", "most likely underlying cause", "patients symptoms"]}
{"question": "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?", "answer": "67%", "options": {"A": "67%", "B": "100%", "C": "75%", "D": "50%"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["35 year old woman", "physician", "genetic counseling prior to conception", "younger brother", "mild developmental delay", "pale complexion", "to limit", "dietary", "phenylalanine", "similar symptoms", "good health", "parents", "healthy", "following", "most appropriate assessment", "carrier status", "disease affecting", "brother"]}
{"question": "A 23-year-old man presents with swelling of the left knee. He noticed the swelling a day ago while preparing for the college basketball game. He has had approximately 10 different sexual partners in the past 3 months. Synovial fluid tap shows a WBC count of 90,000 cells/mm3. What is the mechanism of action of the drug which is indicated for the treatment of this patient’s most likely condition?", "answer": "Cell wall inhibitor", "options": {"A": "Metabolic inhibitor", "B": "Cell wall inhibitor", "C": "Neutrophil migration inhibitor", "D": "Prostaglandin inhibitor"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["23 year old man presents", "swelling of", "left knee", "swelling", "day", "preparing", "college basketball game", "approximately 10 different sexual partners", "past 3 months", "Synovial fluid tap shows", "WBC count", "90", "cells/mm3", "mechanism of action", "drug", "indicated", "treatment", "patients", "likely condition"]}
{"question": "Which of the following patient presentations seen in a pediatric immunology clinic is most consistent with a diagnosis of Bruton's agammaglobulinemia?", "answer": "A 9-month-old boy who has had recurrent otitis media and pneumococcal pneumonia in the past three months", "options": {"A": "A 15-month-old girl who has had repeated otitis media, pneumonia, and progressive clumsiness since beginning to walk in the past three months", "B": "A 10-month-old boy who has had recurrent viral infections as well as hypocalcemia during neonatal period", "C": "A 4-year-old girl who has had repeated oral candidasis in the past nine months", "D": "A 9-month-old boy who has had recurrent otitis media and pneumococcal pneumonia in the past three months"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["following patient presentations seen in", "pediatric immunology clinic", "most consistent with", "diagnosis", "Bruton's agammaglobulinemia"]}
{"question": "A 29-year-old man is brought to the emergency department by a concerned neighbor. The patient appears disheveled, has a flat affect, and appears to be having auditory hallucinations. He is alert and oriented to time, person, and place and has an intact long-term and short-term memory. His neighbor says that he never really knew the patient that well and that he mostly kept to himself. They have been neighbors for the past 3 years at an apartment close to the hospital. What worried the neighbor was a sudden change in the patient's behavior which started last week. He suddenly seemed interested in attending all the local council meetings and social gatherings. He is very talkative at these events and boasts highly of himself and starts suggesting changes that the committee could make with his help. He gets very agitated when they deny accepting his suggestions. Which of the following is a predictor of good prognosis for this patient's condition?", "answer": "Affective symptoms", "options": {"A": "Affective symptoms", "B": "Being single", "C": "Male sex", "D": "Negative symptoms"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["29 year old man", "brought", "emergency department", "neighbor", "patient appears", "flat affect", "appears to", "auditory hallucinations", "alert", "oriented to time", "person", "place", "intact long-term", "short-term memory", "neighbor", "never", "patient", "well", "mostly kept", "neighbors", "past", "years", "apartment close", "hospital", "worried", "neighbor", "sudden change in", "patient's behavior", "started last week", "interested", "attending", "local council meetings", "social gatherings", "very talkative", "events", "boasts highly", "starts suggesting changes", "committee", "make", "help", "gets very agitated", "deny accepting", "suggestions", "following", "predictor", "good prognosis", "patient's condition"]}
{"question": "A 23-year-old man comes to the clinic for yellowing of his eyes. The patient has been relatively healthy and just recently started “intermittent fasting” to try to lose weight. He recalls a similar episode 4 years ago when he was recovering from an emergency appendectomy. The patient denies smoking but endorses an episode of binge drinking 2 days ago. He is sexually active with both men and women. His physical examination is unremarkable besides scleral icterus. What is the most likely explanation for this patient’s symptoms?", "answer": "Decreased activity of UDP-glucuronosyltransferase", "options": {"A": "Autoimmune-mediated fibrosis of biliary tract", "B": "Chronic viral infection of the liver", "C": "Decreased activity of UDP-glucuronosyltransferase", "D": "Defective bilirubin excretion"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["23 year old man", "clinic", "yellowing", "eyes", "patient", "relatively healthy", "recently started intermittent fasting to", "to", "weight", "recalls", "similar episode", "years", "recovering from", "emergency appendectomy", "patient denies smoking", "episode of binge drinking 2 days", "sexually active with", "men", "women", "physical examination", "unremarkable", "scleral icterus", "most likely explanation", "patients symptoms"]}
{"question": "A 40-year-old woman comes to the physician because of a 2-month history of increasingly frequent episodes of vertigo and feeling unsteady while walking. She reports that she has had episodic tinnitus in her right ear for the past 3 years. Neurologic examination shows hearing loss in the right ear. An MRI of the brain is shown. Pathologic examination of this patient's lesion is most likely to show which of the following?", "answer": "Hypercellular areas of spindle cells and hypocellular areas of myxoid stroma", "options": {"A": "Whorls of densely packed cells with areas of lamellated calcification", "B": "Small blue cells arranged in rosettes around a central neuropil", "C": "Hypercellular areas of spindle cells and hypocellular areas of myxoid stroma", "D": "Cells with clear cytoplasm and central round nucleus resembling a fried egg"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["40 year old woman", "physician", "of", "2 month history", "frequent episodes", "vertigo", "feeling unsteady", "walking", "reports", "episodic tinnitus", "right ear", "past", "years", "Neurologic examination shows hearing loss in", "right ear", "MRI of", "brain", "shown", "Pathologic examination of", "patient's lesion", "most likely to show", "following"]}
{"question": "A 47-year-old female presents to her primary physician for follow up after an ED visit for nephrolithiasis 1 week prior. CT scan in the ED revealed a 4-mm stone occluding the right ureter. She was able to pass the stone without assistance over the course of 5 hours. Pathology report on the stone states it was composed of calcium oxalate. She says that the pain of passing the stone was excruciating and asks how she can prevent kidney stones in the future. Which of the following interventions is most likely to prevent renal calculi formation in the future for this patient?", "answer": "Decreasing sodium intake", "options": {"A": "Decreasing calcium intake", "B": "Decreasing sodium intake", "C": "Increasing consumption of nuts and seeds", "D": "Urine acidification with cranberry juice"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old female presents", "primary physician", "follow up", "ED visit", "nephrolithiasis prior", "CT scan", "ED revealed", "4-mm stone occluding", "right ureter", "able to pass", "stone", "assistance", "course", "hours", "Pathology report", "stone states", "calcium oxalate", "pain", "stone", "excruciating", "prevent kidney stones in", "future", "following interventions", "most likely to prevent renal calculi formation", "future", "patient"]}
{"question": "A 62-year-old man comes to the physician because of worsening involuntary movements of both arms for the past 7 months. He reports that certain daily activities have become more difficult to perform. His father had a similar condition that was treated with medications. The patient appears anxious. Vital signs are within normal limits. Examination shows a low-amplitude tremor bilaterally when the arms are outstretched that worsens when reaching out to grab a pen. Muscle strength and tone is normal bilaterally. Deep tendon reflexes are 2+ bilaterally. On mental status examination, his mood is good. His speech is normal in rate and rhythm. Which of the following is the most appropriate next step in management?", "answer": "Propranolol therapy", "options": {"A": "Deep brain stimulation", "B": "Thalamotomy", "C": "Levodopa and carbidopa therapy", "D": "Propranolol therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["62 year old man", "physician", "worsening involuntary movements", "arms", "past", "months", "reports", "certain daily activities", "more difficult to perform", "father", "similar condition", "treated with medications", "patient appears anxious", "Vital signs", "normal limits", "Examination shows", "low amplitude tremor", "arms", "worsens", "reaching out to grab", "pen", "Muscle strength", "tone", "normal", "Deep tendon reflexes", "2", "mental", "mood", "good", "speech", "normal", "rate", "rhythm", "following", "most appropriate next step", "management"]}
{"question": "Ten days after undergoing a cadaveric renal transplant, a 21-year-old man has pain in the right lower abdomen and generalized fatigue. During the past 2 days, he has had decreasing urinary output. He passed 5 liters of urine on the second postoperative day and serum studies showed a creatinine concentration of 2.1 mg/dL. He has adult polycystic kidney disease and was on maintenance hemodialysis for 2 months prior to transplantation. Current medications include azathioprine, cyclosporine, prednisone, and enalapril. He appears lethargic. His temperature is 37.8°C (100°F), pulse is 101/min, and blood pressure is 164/94 mm Hg. Examination shows a healing surgical incision in the right lower abdomen. The graft site shows tenderness to palpation. His blood urea nitrogen concentration is 52 mg/dL, creatinine concentration is 4.1 mg/dL. A biopsy of the transplanted kidney shows tubulitis. C4d staining is negative. Which of the following is the most likely responsible for this patient's findings?", "answer": "Recipient T-cells in the graft", "options": {"A": "Recipient T-cells in the graft", "B": "Drug-induced nephrotoxicity", "C": "Fibrosis of the glomerular vessels", "D": "Newly formed anti-HLA antibodies\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Ten days", "cadaveric renal transplant", "21-year-old man", "pain", "right lower abdomen", "generalized fatigue", "past 2 days", "decreasing urinary output", "passed 5 liters", "urine", "second postoperative day", "serum studies showed", "creatinine concentration", "2", "mg dL", "adult polycystic kidney disease", "maintenance hemodialysis", "2 months prior to transplantation", "Current medications include azathioprine", "cyclosporine", "prednisone", "enalapril", "appears lethargic", "temperature", "pulse", "min", "blood pressure", "mm Hg", "Examination shows", "healing", "right lower", "graft site shows tenderness", "palpation", "blood nitrogen concentration", "mg/dL", "creatinine concentration", "4.1 mg/dL", "biopsy of", "transplanted kidney shows tubulitis", "C4d staining", "negative", "following", "most likely responsible", "patient's findings"]}
{"question": "A 58-year-old woman presents to the office for routine follow-up. She recently underwent routine screening for bone density due to a history of hypothyroidism. She also has a history of gastroesophageal reflux disease (GERD) that is being treated with a proton-pump inhibitor (PPI) and more recently with a histamine2 receptor antagonist (H2RA), hypertension being treated with a thiazide diuretic, depression being treated with lithium, and hormone replacement therapy. Her results meet the criteria for osteopenia, with a T-score of -1.6. She is concerned about progressive bone loss and the risk of fractures. Which of the following medication classes should be discontinued?", "answer": "Proton-pump inhibitors", "options": {"A": "Proton-pump inhibitors", "B": "Thiazide diuretics", "C": "Lithium", "D": "Estrogen"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["58 year old woman presents", "office", "routine follow-up", "recently", "routine screening", "bone density due to", "history of hypothyroidism", "history of gastroesophageal reflux disease", "treated with", "proton-pump inhibitor", "more recently", "histamine2 receptor antagonist", "hypertension", "treated with", "thiazide diuretic", "depression", "treated with lithium", "hormone replacement therapy", "results meet", "criteria", "osteopenia", "a T score", "1", "concerned", "progressive bone loss", "risk", "fractures", "following medication classes", "discontinued"]}
{"question": "A 46-year-old man is brought to the emergency department 15 minutes after being involved in a motor vehicle collision where he was the unrestrained driver. On arrival, he is unconscious. His respirations are 24/min, and palpable systolic blood pressure is 60 mm Hg, and pulse is 141/min and irregularly irregular. Examination shows multiple ecchymoses over the chest. There is a 3-cm (1.2-in) laceration over the abdomen and a 4-cm (1.6-in) laceration over the scalp. Jugular venous pressure is increased. Bilateral crackles are heard at the lung bases. Cardiac examination shows no murmurs, rubs, or gallops. The abdomen is soft. Two large bore intravenous catheters are inserted and 0.9% saline infusion is begun. Focused assessment with sonography in trauma (FAST) is negative. An electrocardiogram shows absent p-waves. After 5 minutes, his pulse is 160/min and palpable systolic blood pressure is 50 mm Hg. Vasopressors are administered. One hour later, the patient dies. Which of the following was the most likely diagnosis?", "answer": "Cardiac contusion", "options": {"A": "Cardiac contusion", "B": "Hemothorax", "C": "Aortic dissection", "D": "Pulmonary contusion"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old man", "brought", "emergency department 15 minutes", "involved", "motor vehicle collision", "driver", "arrival", "unconscious", "respirations", "min", "palpable systolic blood pressure", "60 mm Hg", "pulse", "min", "irregular", "Examination shows multiple ecchymoses", "chest", "3", "1.2", "laceration", "abdomen", "4", "1.6", "laceration", "scalp", "Jugular venous pressure", "increased", "Bilateral crackles", "heard", "lung bases", "Cardiac examination shows", "murmurs", "rubs", "abdomen", "soft", "Two large bore intravenous catheters", "inserted", "0.9", "saline infusion", "begun", "Focused assessment", "sonography", "trauma", "negative", "electrocardiogram shows absent p-waves", "5 minutes", "pulse", "min", "palpable systolic blood pressure", "50 mm Hg", "Vasopressors", "administered", "One hour later", "patient", "following", "most likely diagnosis"]}
{"question": "A 65-year-old man with a longstanding history of poorly-controlled hypertension and no recent illness or cardiac disease presents to clinic complaining of chest pain that is worse on inspiration and relieved by sitting forward. Vital signs are stable. On exam, you detect a friction rub. Routine labs show K 7.5 and Cr 5.1. If this patient's clinical signs and laboratory findings are indicative of a chronic condition, what would be expected on urinary analysis?", "answer": "Broad and waxy casts", "options": {"A": "Muddy brown granular casts", "B": "Red blood cell casts", "C": "Fatty casts", "D": "Broad and waxy casts"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["65-year-old man", "history of poorly controlled hypertension", "recent illness", "cardiac disease presents", "clinic", "of chest pain", "worse", "inspiration", "relieved by sitting forward", "Vital signs", "stable", "exam", "detect", "friction rub", "Routine labs show K", "5", "Cr 5", "patient's clinical signs", "laboratory findings", "chronic condition", "expected", "urinary analysis"]}
{"question": "A 56-year-old man of Korean descent visits his primary care provider for an annual health check-up. His personal history is relevant for cigarette smoking and a sedentary lifestyle. He has type-2 diabetes mellitus which is under control with oral medications. Upon physical examination, he is found to have a blood pressure of 130/70 mm Hg, a pulse of 72/min, a respiratory rate of 18/min, and a body temperature of 36.5°C (97.7°F). The rest of the examination is unremarkable except for an enlarged, nontender left supraclavicular node. In addition to a fine needle aspiration or biopsy, which of the following tests should also be included in further assessment of this patient?", "answer": "Upper gastointestinal endoscopy", "options": {"A": "Chest radiograph", "B": "Upper gastointestinal endoscopy", "C": "Magnetic resonance imaging of the brain", "D": "Ultrasound of the neck"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old man", "Korean descent visits", "primary care provider", "annual health check-up", "personal history", "relevant", "cigarette smoking", "sedentary lifestyle", "type-2 diabetes mellitus", "control", "oral medications", "physical examination", "found to", "blood pressure", "70 mm Hg", "pulse", "72 min", "respiratory rate", "min", "body temperature", "36", "97", "rest", "examination", "unremarkable", "enlarged", "nontender left supraclavicular node", "fine needle aspiration", "biopsy", "following tests", "included", "further assessment", "patient"]}
{"question": "A 46-year-old woman presents with a 5-month history of worsening dry cough, occasional shortness of breath, and fatigue. She says she is now having trouble walking a full block. For the past week, she also has noticed bilateral swelling of the lower legs. She denies chest pain, fever, chills, syncope, or bloody sputum. Current vitals include: temperature 37.0°C (98.6°F), pulse 63/min, blood pressure 128/91 mm Hg and respiratory rate 15/min. On physical examination, there is elevated jugular venous pressure, decreased breath sounds bilaterally at the lung bases, and 1+ non-pitting edema bilaterally in the lower extremities. A chest X-ray demonstrates a slightly enlarged cardiac silhouette. Which of the following is the most appropriate next step in the diagnosis of this patient?", "answer": "Echocardiography", "options": {"A": "Bronchoalveolar wash", "B": "Pulmonary function studies", "C": "Echocardiography", "D": "Chest CT"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "month history", "worsening dry cough", "occasional shortness of breath", "fatigue", "now", "walking", "full block", "past week", "bilateral swelling of", "lower legs", "denies chest pain", "fever", "chills", "syncope", "bloody sputum", "Current", "include", "temperature", "98", "pulse 63 min", "blood pressure", "mm Hg", "respiratory rate", "min", "physical examination", "elevated jugular venous pressure", "decreased breath sounds", "lung bases", "1", "non pitting edema", "lower extremities", "chest X-ray demonstrates", "slightly enlarged cardiac silhouette", "following", "most appropriate next step", "diagnosis", "patient"]}
{"question": "A 67-year-old woman with depression comes to the physician because of easy bruising and bleeding of her gums for the past 2 months. She has been living alone since the death of her husband 1 year ago. She appears thin and has temporal wasting bilaterally. Physical examination shows bruises on her lower legs, swollen gums, and petechiae on the hard palate. This patient's symptoms are most likely due to defective synthesis of a substance that is composed primarily of which of the following amino acids?", "answer": "Glycine", "options": {"A": "Glycine", "B": "Proline", "C": "Lysine", "D": "Arginine"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["67 year old woman", "depression", "physician", "easy bruising", "bleeding", "gums", "past", "months", "living alone", "death", "husband", "year", "appears thin", "temporal wasting", "Physical examination shows bruises", "lower legs", "swollen gums", "petechiae", "hard palate", "patient's symptoms", "most likely due to defective synthesis", "substance", "following amino acids"]}
{"question": "A 49-year-old female with a history of alcoholism was found lying unconscious on a bench at a local park and rushed to the emergency department. Upon arrival, the patient regained consciousness and complained of intense bilateral flank pain and a recent decrease in urination. Urine microscopy demonstrated abundant square crystals of calcium oxalate that looked like “folded envelopes.\" Which of the following findings is most likely to be seen in this patient:", "answer": "Anion gap metabolic acidosis", "options": {"A": "Anion gap metabolic acidosis", "B": "Non-anion gap metabolic acidosis", "C": "Respiratory acidosis", "D": "Respiratory alkalosis"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old female", "history of alcoholism", "found lying unconscious", "local park", "rushed", "emergency department", "arrival", "patient regained consciousness", "intense bilateral flank pain", "recent decrease", "urination", "Urine microscopy", "abundant square crystals", "calcium oxalate", "looked", "folded envelopes", "following findings", "most likely to", "seen", "patient"]}
{"question": "A 53-year-old man comes to the physician for a follow-up appointment three days after being prescribed a selective alpha-1 agonist. He reports improvement in his symptoms and has not experienced any adverse effects. This drug was most likely prescribed for which of the following conditions?", "answer": "Nasal congestion due to a viral infection", "options": {"A": "Bronchospasm due to bronchial asthma", "B": "Urinary hesitancy due to benign prostatic hyperplasia", "C": "Nasal congestion due to a viral infection", "D": "Blood pressure management prior to pheochromocytoma excision"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man", "physician", "follow-up appointment three days", "prescribed", "selective alpha-1 agonist", "reports improvement", "symptoms", "not experienced", "adverse effects", "drug", "most likely prescribed", "following conditions"]}
{"question": "A 31-year-old woman is brought to the emergency department with fever, right upper quadrant pain, and myalgia. Her boyfriend says she recently returned from a trip to Southeast Asia. She appears ill and is lethargic. Her temperature is 39°C (102.2°F). Physical examination shows jaundice and tender hepatomegaly. Laboratory studies show the presence of anti-hepatitis A IgM antibodies. A liver biopsy performed at this time would most likely show which of the following histopathological findings?", "answer": "Hepatocytes with shrunken, eosinophilic cytoplasm and pyknotic nuclei", "options": {"A": "Hepatocytes with shrunken, eosinophilic cytoplasm and pyknotic nuclei", "B": "Cystic spaces with scattered areas of cellular debris", "C": "Basophilic adipocyte remnants, filled with calcifications", "D": "Engorged hepatocytes with red blood cell infiltration\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["31 year old woman", "brought", "emergency department", "fever", "right upper quadrant pain", "myalgia", "boyfriend", "recently returned", "trip", "Southeast Asia", "appears ill", "lethargic", "temperature", "Physical examination shows jaundice", "tender hepatomegaly", "Laboratory studies show", "presence", "hepatitis", "IgM antibodies", "liver biopsy performed", "time", "most likely show", "following histopathological findings"]}
{"question": "A 25-year-old man presents to his primary care physician for pain in his back. The patient describes the pain as feeling worse in the morning. He says it is a general stiffness that improves when he goes to the gym and lifts weights. He also states that his symptoms seem to improve when he leans forward or when he is cycling. The patient is a current smoker and is sexually active. He admits to having unprotected sex with many different partners this past year. The patient has no significant past medical history and is not currently taking any medications. On physical exam, the patient demonstrates notable kyphosis of the thoracic spine and decreased mobility of the back in all 4 directions. The patient’s strength is 5/5 in his upper and lower extremities. The rest of his physical exam is within normal limits. Which of the following findings is associated with this patient’s presentation?", "answer": "Punctate bleeding spots when dermatologic scales are removed", "options": {"A": "Diminished pulses in the lower extremity", "B": "Narrowing of the spinal canal when standing upright", "C": "Pain with elevation of his leg while laying down", "D": "Punctate bleeding spots when dermatologic scales are removed"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old man presents", "primary care physician", "pain in", "back", "patient", "pain", "feeling worse", "morning", "general stiffness", "improves", "goes", "lifts weights", "states", "symptoms", "to", "forward", "cycling", "patient", "current smoker", "sexually active", "admits to", "sex", "different partners", "past year", "patient", "significant past medical history", "not currently taking", "medications", "physical exam", "patient demonstrates notable kyphosis of", "thoracic spine", "decreased mobility of", "back", "4 directions", "patients strength", "5/5", "upper", "lower extremities", "rest", "physical exam", "normal limits", "following findings", "associated with", "patients presentation"]}
{"question": "A 9-month-old boy is brought to his pediatrician by his mother for a routine health checkup. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. He was breastfed for the first 3 months and then switched to cow’s milk and about two months ago she started giving him fruits and vegetables. Family history is noncontributory. Today, his heart rate is 120/min, respiratory rate is 40/min, blood pressure is 90/50 mm Hg, and temperature of 37.0°C (98.6°F). On examination, he has a heartbeat with a regular rate and rhythm and his lungs are clear to auscultation bilaterally. Generally, the boy looks pale. His weight and height fall within the expected range. A complete blood count (CBC) shows the following:\nHemoglobin (Hb): 9.1 g/dL\nMean corpuscular volume (MCV): 65 fL\nTotal iron binding capacity (TIBC): 550 μg/dL\nSerum iron: 45 µg/dL\nSerum lead: < 5 µg/dL\nWhat is the best treatment for this patient?", "answer": "Proper diet and iron supplementation", "options": {"A": "Iron supplementation only", "B": "Proper diet and iron supplementation", "C": "Multivitamins", "D": "Proper diet only"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["month old boy", "brought", "pediatrician", "mother", "routine health checkup", "boy", "born", "weeks gestation", "spontaneous vaginal delivery", "date", "vaccines", "meeting", "developmental milestones", "breastfed", "first", "months", "then switched", "cows milk", "about two months", "started giving", "fruits", "vegetables", "Family history", "Today", "heart rate", "min", "respiratory rate", "40 min", "blood pressure", "90 50 mm Hg", "temperature", "98", "examination", "heartbeat", "regular rate", "rhythm", "lungs", "clear", "auscultation", "boy looks pale", "weight", "height fall", "expected range", "complete blood count", "CBC", "shows", "following", "Hemoglobin", "g/dL Mean corpuscular volume", "65 fL Total iron binding capacity", "550 g/dL Serum iron", "g/dL Serum lead", "5 g/dL", "best treatment", "patient"]}
{"question": "A 39-year-old woman, with a history of thyroidectomy and primary hyperparathyroidism presents for surgical evaluation for a right adrenal mass. Preoperatively, which of the following medications should she receive to prevent a hypertensive emergency intraoperatively?", "answer": "Phenoxybenzamine", "options": {"A": "Atenolol", "B": "Labetolol", "C": "Nifedipine", "D": "Phenoxybenzamine"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "history of thyroidectomy", "primary hyperparathyroidism presents", "surgical evaluation", "right adrenal mass", "following medications", "receive to prevent", "hypertensive emergency"]}
{"question": "A 58-year-old male is diagnosed with hypertension and started on daily propranolol after failing antihypertensive therapy with other medications. Three months later, his blood pressure appears to be adequately controlled on this therapy. While working in his garden one afternoon, the patient is stung by a wasp and experiences a severe anaphylactic reaction that is subsequently treated with epinephrine. Which of the following effects would be expected upon administration of this epinephrine treatment?", "answer": "Decreased heart rate", "options": {"A": "Decreased bronchodilation", "B": "Increased motility of the gastrointestinal tract", "C": "Decreased heart rate", "D": "Increased heart rate"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["58 year old male", "diagnosed", "hypertension", "started", "daily propranolol", "failing antihypertensive", "medications", "Three months later", "blood pressure appears to", "controlled", "therapy", "working", "garden one afternoon", "patient", "stung", "wasp", "experiences", "severe anaphylactic reaction", "treated with epinephrine", "following effects", "expected", "administration", "epinephrine treatment"]}
{"question": "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:\nNa+ 145 mEq/L\nK+ 4.1 mEq/L\nCl- 102 mEq/L\nHCO3- 25 mEq/L\nCa2+ 9.4 mg/dL\nGlucose 110 mg/dL\nThyroid-stimulating hormone 0.3 μU/mL\nThyroxine 3.9 μg/dL\nInsulin-like growth factor 1 24 ng/mL (N=61–356 ng/mL)\nInsulin-like growth factor binding protein 3 2.1 mcg/mL (N=1.6–6.5 μg/mL)\nWhich of the following is the most likely diagnosis?\"", "answer": "Craniopharyngioma", "options": {"A": "Rathke cleft cyst", "B": "Craniopharyngioma", "C": "Multiple endocrine neoplasia", "D": "Pituitary adenoma"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "physician", "parents", "short stature", "clothing", "shoe size", "changed", "past year", "frequently", "furniture", "headaches", "night", "always thirsty", "cold water", "more frequently", "Three years", "asthma attack", "treated with albuterol", "one-week course", "steroids", "mother", "Hashimoto", "hyroiditis ", "recocious puberty.", "other'", "ight i", "f  1  i", "ther's", "ght is", "t 3 ", " pe centile fo", "ght an", " pe centile fo", "ght. H", "perature is", "6F", "se is", "mi , r", "pirations ar", ", a", "od pressure is", "/64 mm Hg. E", "mination sh ws a ", "t an", "tender ab omen. T", "itals an", "ic hair ar", "ner st", "llary hair is", "ent. P", "ellar reflexes ar", "b", "oratory studies sh w: N", " 1", "/L K+ 4", "  E", " 1", "3- 2", "+ 9", "dL", "dL", "roid-stimulating hormone 0.  U/", "Th", "ulin-like growth factor 1 ", "mL (N", "1", "mL) I", "ulin-like growth factor binding protein 3 2.", "(N", ". 6 5  / L) W", "lowing is", "t likely di gnosis?\""]}
{"question": "A 31-year-old woman, gravida 2, para 1, at 32 weeks' gestation presents to the emergency department for clear vaginal discharge that started roughly 26 hours ago. Her pregnancy has been uncomplicated. Her first child was born at term by vaginal delivery. She has no history of any serious illnesses. She does not drink alcohol or smoke cigarettes. Current medications include vitamin supplements. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Speculum examination demonstrates clear fluid at the cervical os. The fetal heart rate is reactive at 160/min with no decelerations. Tocometry shows uterine contractions. Nitrazine testing is positive. She is started on indomethacin. Which of the following is the most appropriate next step in management?", "answer": "Administer betamethasone, ampicillin, and proceed with cesarean section", "options": {"A": "Administer ampicillin and perform amnioinfusion", "B": "Administer ampicillin and progesterone", "C": "Administer betamethasone, ampicillin, and proceed with cesarean section", "D": "Administer betamethasone, ampicillin, and proceed with induction of labor"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["31 year old woman", "gravida 2", "para 1", "weeks", "gestation presents", "emergency department", "clear vaginal discharge", "started", "hours", "pregnancy", "uncomplicated", "first child", "born", "term", "vaginal delivery", "history", "serious illnesses", "not drink alcohol", "smoke cigarettes", "Current medications include vitamin supplements", "temperature", "98 9F", "pulse", "70 min", "respirations", "min", "blood pressure", "mm Hg", "Speculum examination demonstrates clear fluid", "cervical os", "fetal heart rate", "reactive", "min", "decelerations", "shows uterine contractions", "testing", "positive", "started", "indomethacin", "following", "most appropriate next step", "management"]}
{"question": "A 63-year-old man comes to the emergency department because of a 4-day history of lower abdominal pain, fever, and nausea. He has a history of constipation. His temperature is 39.1°C (102.4°C). Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. Laboratory studies show a leukocyte count of 19,000/mm3. A CT scan of the abdomen shows segmental wall thickening of the descending colon with multiple diverticula and a 5.0-cm, low-attenuation pelvic lesion with air-fluid levels. CT-guided drainage of the fluid collection yields 250 mL of yellow-greenish fluid. Release of which of the following substances is most likely responsible for the formation of the drained lesion?", "answer": "Lysosomal enzymes", "options": {"A": "Staphylococcal coagulase", "B": "Lipoteichoic acid", "C": "Interleukin-3", "D": "Lysosomal enzymes"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["63 year old man", "emergency department", "4-day history", "lower abdominal pain", "fever", "nausea", "history", "constipation", "temperature", "4C", "Abdominal examination shows left lower quadrant tenderness", "guarding", "Laboratory studies show", "leukocyte count", "mm3", "CT scan", "abdomen shows segmental wall thickening of", "descending colon", "multiple diverticula", "5 0", "low attenuation pelvic lesion", "air-fluid levels", "CT-guided drainage", "collection", "mL", "yellow", "fluid", "Release", "following substances", "most likely responsible", "formation", "drained lesion"]}
{"question": "A researcher is studying risk factors for open-angle glaucoma in a group of elderly patients at a primary care clinic. He is curious if patients with diabetes (defined as fasting serum glucose ≥126 mg/dL on two separate readings) are at increased risk of developing open-angle glaucoma over time. Which of the following is the best statement of the null hypothesis for this study?", "answer": "The future risk of open-angle glaucoma is the same in patients with and those without diabetes", "options": {"A": "The future risk of open-angle glaucoma is the same in patients with and those without diabetes", "B": "Having diabetes will not cause changes in risk of future open-angle glaucoma", "C": "Diabetes is not associated with an increased prevalence of open-angle glaucoma", "D": "Improved adherence to antidiabetics will not be effective in decreasing future open-angle glaucoma risk"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["researcher", "studying risk factors", "open-angle glaucoma", "a group", "elderly patients", "primary care clinic", "curious", "patients", "diabetes", "defined", "fasting serum glucose", "mg dL", "two separate readings", "increased risk", "open-angle glaucoma", "time", "following", "best statement", "null hypothesis", "study"]}
{"question": "Background:\nSome patients with severe asthma have frequent exacerbations associated with persistent eosinophilic inflammation despite continuous treatment with high-dose inhaled glucocorticoids with or without oral glucocorticoids.\nMethods:\nIn this randomized, double-blind clinical trial we assigned 576 patients with recurrent asthma exacerbations and evidence of eosinophilic inflammation despite high doses of inhaled glucocorticoids to one of three study groups. Patients were assigned to receive mepolizumab, a humanized monoclonal antibody against interleukin-5, which was administered as either a 75-mg intravenous dose or a 100-mg subcutaneous dose or placebo every 4 weeks for 32 weeks. The primary outcome was the rate of exacerbations. Other outcomes included the forced expiratory volume in 1 second (FEV1) and scores on the St. George’s Respiratory Questionnaire (SGRQ) and the 5-item Asthma Control Questionnaire (ACQ-5).\nResults:\nThe rate of exacerbations was reduced by 47% (95% confidence interval [CI], 29 to 61) among patients receiving intravenous mepolizumab and by 53% (95% CI, 37 to 65) among those receiving subcutaneous mepolizumab, as compared with those receiving placebo (p<0.001 for both comparisons). Exacerbations necessitating an emergency department visit or hospitalization were reduced by 32% in the group receiving intravenous mepolizumab and by 61% in the group receiving subcutaneous mepolizumab. At week 32, the mean increase from baseline in FEV1 was 100 ml greater in patients receiving intravenous mepolizumab than in those receiving placebo (p=0.02) and 98 ml greater in patients receiving subcutaneous mepolizumab than in those receiving placebo (p=0.03). The improvement from baseline in the SGRQ score was 6.4 points and 7.0 points greater in the intravenous and subcutaneous mepolizumab groups, respectively than in the placebo group, and the improvement in the ACQ-5 score was 0.42 points and 0.44 points greater in the two mepolizumab groups, respectively than in the placebo group (p<0.001 for all comparisons).\nConclusions:\nMepolizumab administered either intravenously or subcutaneously significantly reduced asthma exacerbations and was associated with improvements in markers of asthma control.\nGiven the original research abstract above, which of the following would be true if the authors had inadvertently encountered a type 1 error?", "answer": "A type 1 error occurs when the null hypothesis is true but is rejected in error.", "options": {"A": "A type 1 error occurs when the null hypothesis is true but is rejected in error.", "B": "A type 1 error occurs when the null hypothesis is false, yet is accepted in error.", "C": "A type 1 error is a beta (β) error and is usually 0.1 or 0.2.", "D": "A type 1 error is dependent on the confidence interval of a study."}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["Background", "patients", "severe asthma", "frequent exacerbations associated with persistent eosinophilic", "continuous treatment", "high-dose inhaled glucocorticoids", "oral glucocorticoids", "Methods", "randomized", "double-blind clinical trial", "assigned", "patients", "recurrent asthma exacerbations", "evidence", "eosinophilic inflammation", "high doses", "inhaled glucocorticoids", "one", "three study groups", "Patients", "assigned to receive mepolizumab", "humanized monoclonal antibody", "interleukin-5", "administered", "75 mg intravenous dose", "100 mg subcutaneous dose", "placebo", "4 weeks", "primary outcome", "rate", "exacerbations", "outcomes included", "forced expiratory volume in 1 second", "scores", "St", "Respiratory Questionnaire", "5 item Asthma Control Questionnaire", "Results", "rate", "exacerbations", "reduced", "95", "confidence interval", "29", "61", "patients receiving intravenous mepolizumab", "95", "CI", "65", "receiving subcutaneous mepolizumab", "compared", "receiving placebo", "p 0.001", "comparisons", "Exacerbations", "emergency visit", "hospitalization", "reduced", "group receiving intravenous mepolizumab", "61", "group receiving subcutaneous mepolizumab", "week", "mean increase", "baseline in FEV1", "100 ml greater", "patients receiving intravenous mepolizumab", "receiving placebo", "p 0.02", "98 ml greater", "patients receiving subcutaneous mepolizumab", "receiving placebo", "p 0.03", "improvement", "baseline", "score", "6.4 points", "0 points greater", "intravenous", "subcutaneous mepolizumab groups", "placebo group", "improvement", "ACQ-5 score", "0.42 points", "0.44 points greater", "two mepolizumab groups", "placebo group", "p 0.001", "comparisons", "Conclusions", "Mepolizumab administered either", "reduced asthma exacerbations", "associated with improvements", "markers", "asthma control", "Given", "original research abstract", "following", "true", "authors", "encountered", "type 1 error"]}
{"question": "A 30-year-old Japanese woman is brought to the emergency department after fainting at work. She says she was only unconscious for a moment and recovered quickly. She reports increasing fatigue and joint pain for the past 4 months. Her blood pressure is 90/60 mm Hg, and her temperature is 36.6°C (98.0°F). On physical examination, the patient is fully conscious. Her radial pulse is absent at her right wrist and 1+ at her left wrist. Laboratory findings are significant for the following:\nHemoglobin: 10.9 g/dL\nHematocrit: 34.7%\nLeukocyte count: 5,500/mm3\nNeutrophils: 65%\nLymphocytes: 30%\nMonocytes: 5%\nMean corpuscular volume: 78.2 μm3\nPlatelet count: 190,000/mm3\nErythrocyte sedimentation rate: 56 mm/h\nWhat complications is this patient at risk for?", "answer": "Myocardial infarction", "options": {"A": "Myocardial infarction", "B": "Tongue infarction", "C": "Palpable purpura", "D": "Polyneuropathy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["30 year old Japanese woman", "brought", "emergency department", "fainting", "work", "only unconscious", "recovered", "reports increasing fatigue", "joint pain", "past", "months", "blood pressure", "90 60 mm Hg", "temperature", "36", "98", "physical examination", "patient", "fully conscious", "radial pulse", "absent", "right wrist", "1", "left wrist", "Laboratory findings", "significant", "following", "Hemoglobin", "10.9 g dL Hematocrit", "Leukocyte count", "5 500 mm3 Neutrophils", "65", "Lymphocytes", "30", "Monocytes", "5", "Mean corpuscular volume", "m3 Platelet count", "mm3 Erythrocyte sedimentation rate", "mm/h", "complications", "patient at risk"]}
{"question": "A 25-year-old woman comes to the physician because of an acute, painful swelling of the left labia that she first noticed that morning. She also reports some pain while sitting and walking. She is sexually active with her boyfriend and states that she has been having pain during vaginal intercourse lately. She has no history of serious illness. She appears uncomfortable. Her temperature is 38°C (100.4°F), pulse is 90/min, and blood pressure 120/80 mm Hg. Pelvic examination shows a left-sided, tender mass surrounded by edema and erythema in the left inner labia. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?", "answer": "Incision and drainage", "options": {"A": "Cryotherapy", "B": "Incision and drainage", "C": "Biopsy", "D": "Trimethoprim-sulfamethoxazole"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "of", "acute", "painful swelling", "the left labia", "first", "morning", "reports", "pain", "sitting", "walking", "sexually active", "boyfriend", "states", "pain", "vaginal", "history", "serious illness", "appears", "temperature", "100 4F", "pulse", "90 min", "blood pressure", "80 mm Hg", "Pelvic examination shows", "left-sided", "tender mass surrounded", "edema", "erythema", "left inner labia", "examination shows", "abnormalities", "following", "most appropriate next step", "management"]}
{"question": "A 21-year-old female presents to the clinic requesting prenatal counseling. She was born with a disease that has led her to have recurrent upper respiratory infections throughout her life requiring antibiotic prophylaxis and chest physiotherapy as well as pancreatic enzyme replacement therapy. She marries a man (without this disease phenotype) from a population where the prevalence of this disease is 1/100. What is the chance that their child will have the disease of interest?", "answer": "9/100", "options": {"A": "9/100", "B": "1/10", "C": "81/100", "D": "9/10"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["21-year-old female presents", "clinic requesting prenatal counseling", "born", "disease", "led", "to", "recurrent upper respiratory infections", "life", "antibiotic prophylaxis", "chest physiotherapy", "pancreatic enzyme replacement therapy", "marries", "man", "disease phenotype", "population", "prevalence", "disease", "1 100", "chance", "child", "disease of interest"]}
{"question": "A 45-year-old woman presents to the physician with a history of headache, palpitations, and episodic diaphoresis. She was diagnosed with hypertension in the past and is now regularly taking antihypertensive medication (amlodipine 10 mg once daily). She has had a diffuse thyroid swelling for the past 4 months. She complains of pain in the long bones of her arms and legs for the past 3 months. She is slightly built, appears thin, and is anxious and apprehensive. Her skin is moist and warm. Her weight is 45 kg (99.2 lb) and height is 146 cm (4 ft 7 in); BMI is 21.12 kg/m2. Her pulse is 116/min, the blood pressure is 196/102 mm Hg, the respiratory rate is 29/min, and the temperature is 37.2°C (99.0°F). Diffuse and firm thyromegaly is present. Her upper extremities exhibit fine tremors during an anxiety attack. The laboratory test results reveal elevated 24-hour urinary VMA and metanephrines. Serum epinephrine, calcitonin, and parathormone levels are also elevated. Hypercalcemia and hyperglycemia are also noted. Which of the following is the most likely diagnosis?", "answer": "Multiple endocrine neoplasia (MEN) 2A", "options": {"A": "Von Hippel-Lindau syndrome", "B": "Multiple endocrine neoplasia (MEN) 2A", "C": "Multiple endocrine neoplasia (MEN) 2B", "D": "Neurofibromatosis"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman presents", "physician", "history of headache", "palpitations", "episodic diaphoresis", "diagnosed", "hypertension", "past", "now", "taking antihypertensive medication", "amlodipine 10 mg", "daily", "diffuse thyroid swelling", "past", "months", "pain", "long bones of", "arms", "legs", "past 3 months", "slightly built", "appears thin", "anxious", "apprehensive", "skin", "moist", "warm", "weight", "kg", "99", "height", "4 ft", "BMI", "kg/m2", "pulse", "min", "blood pressure", "mm Hg", "respiratory rate", "29 min", "temperature", "99", "Diffuse", "firm thyromegaly", "present", "upper extremities exhibit fine tremors", "anxiety attack", "laboratory test results reveal elevated", "hour urinary VMA", "metanephrines", "Serum epinephrine", "calcitonin", "parathormone levels", "elevated", "Hypercalcemia", "hyperglycemia", "noted", "following", "most likely diagnosis"]}
{"question": "A 57-year-old man comes to the physician because of a 1-year history of increasing shortness of breath on exertion and a cough productive of a small amount of grayish-white phlegm. The cough had been initially nonproductive. He has not had fever or chest pain. He is originally from China and visits his family there once every year. He has worked as a car salesman for 15 years and worked in a shipyard before that for 22 years. He smoked half a pack of cigarettes daily for 13 years but stopped 25 years ago. His temperature is 37.1°C (98.8°F), pulse is 86/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. Fine expiratory crackles are heard at both lung bases. An x-ray of the chest shows patchy infiltrates and supradiaphragmatic pleural thickening in both lungs. A photomicrograph from a sputum sample is shown. Further evaluation of this patient is most likely to show which of the following findings?", "answer": "Increased alveolar-arterial gradient", "options": {"A": "Increased alveolar-arterial gradient", "B": "Bloody pleural effusion", "C": "Concave flow-volume loop", "D": "Increased diffusing capacity (DLCO)"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["57 year old man", "physician", "of", "year history", "increasing shortness", "breath", "exertion", "cough productive", "small", "grayish white phlegm", "cough", "initially", "not", "fever", "chest pain", "China", "visits", "family", "year", "worked", "car salesman", "years", "worked", "years", "smoked half", "pack", "cigarettes daily", "years", "stopped", "years", "temperature", "98", "pulse", "min", "respirations", "min", "blood pressure", "80 mm Hg", "Fine expiratory crackles", "heard", "lung bases", "x-ray of", "chest shows patchy infiltrates", "pleural thickening", "lungs", "photomicrograph", "sputum sample", "shown", "Further evaluation", "patient", "most likely to show", "following findings"]}
{"question": "A 45-year-old woman presents with sudden-onset dyspnea. Her past medical history is significant for varicose veins in her lower extremities, well-controlled diabetes mellitus type 2, and a 25 pack-year smoking history. The patient currently takes metformin and pioglitazone. Family history is significant for her sister who died at the age of 35 because of a pulmonary embolism. Her temperature is 37.8°C (100.0°F), the pulse is 111/min, the respirations are 18/min, and the blood pressure is 130/60 mm Hg. On physical examination, the patient is pale and diaphoretic. Cardiac exam is significant for an S3 gallop. There is erythema and swelling over multiple varicose veins in her left leg. Ultrasound of her left leg is positive for a deep vein thrombosis. The patient is admitted, and anticoagulation is started with a vitamin K inhibitor. However, despite these interventions, she dies shortly after admission. Which of the following was the most likely etiology of this patient’s condition?", "answer": "Protein S deficiency", "options": {"A": "Distal peripheral microembolism", "B": "Necrotizing fasciitis", "C": "Protein S deficiency", "D": "Waldenström macroglobulinemia"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old woman presents", "sudden-onset dyspnea", "past medical history", "significant", "varicose veins", "lower extremities", "well-controlled diabetes mellitus type 2", "pack-year smoking history", "patient currently takes metformin", "pioglitazone", "Family history", "significant", "sister", "died", "age", "35", "pulmonary embolism", "temperature", "100", "pulse", "min", "respirations", "min", "blood pressure", "60 mm Hg", "physical examination", "patient", "pale", "diaphoretic", "Cardiac exam", "significant", "S3 gallop", "erythema", "swelling", "multiple varicose veins", "left leg", "Ultrasound", "positive", "deep vein thrombosis", "patient", "admitted", "anticoagulation", "started", "a vitamin K inhibitor", "interventions", "admission", "following", "most likely etiology", "patients condition"]}
{"question": "A 7-year-old boy is brought to the clinic by his mother with increasing swelling of his right jaw for the past 2 months. She notes that he has been treated several times with different antibiotics, but that they have not helped. She reports no recent history of fever, chills, or night sweats. The boy has no significant medical history. He emigrated to the United States with his family from Nigeria 1 month ago. He is in the 85th percentile for height and weight, and he has been meeting all developmental milestones. His temperature is 37.8℃ (100.0℉). On physical examination, the patient has a prominent 8 × 8 cm mass over the right mandible. The mass has partially distorted the borders of the mandible and cheek. The overlying skin is erythematous. The mass is firm, immobile, and tender. The contralateral side of the face shows no abnormalities. An oral examination shows the disruption of the ipsilateral lower teeth and oral mucosa. The remainder of the physical exam is unremarkable. A biopsy of the mass is performed and a histopathologic analysis is seen in the image. Which of the following microorganisms is most likely associated with this patient’s condition?", "answer": "Epstein barr virus (EBV)", "options": {"A": "Bartonella henselae", "B": "Cytomegalovirus (CMV)", "C": "Epstein barr virus (EBV)", "D": "Yersinia pestis"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old boy", "brought", "clinic", "mother", "increasing swelling", "right jaw", "past", "months", "notes", "treated", "times with different antibiotics", "not helped", "reports", "recent history", "fever", "chills", "night sweats", "boy", "significant medical history", "United States", "family", "Nigeria", "month", "percentile", "height", "weight", "meeting", "developmental milestones", "temperature", "100 0", "physical examination", "patient", "prominent 8", "8 cm mass", "right mandible", "mass", "distorted", "borders of", "mandible", "cheek", "skin", "erythematous", "mass", "firm", "immobile", "tender", "contralateral side of", "face shows", "abnormalities", "oral examination shows", "disruption", "ipsilateral lower teeth", "oral mucosa", "physical exam", "unremarkable", "biopsy", "mass", "performed", "histopathologic analysis", "seen", "image", "following microorganisms", "most likely associated with", "patients condition"]}
{"question": "A 3-year-old male was brought to the pediatrician with severe lip lacerations, with a portion of his tongue appearing to be bitten off, as well as missing portions of the fingers on his right hand. A family history is notable for two similar cases in male cousins on the mother's side. A urinalysis revealed a high level of uric acid. Which of the following is the mode of inheritance for this disorder?", "answer": "X-linked recessive", "options": {"A": "X-linked recessive", "B": "X-linked dominant", "C": "Autosomal dominant", "D": "Maternally inherited mitochondrial defect"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["3 year old male", "brought", "pediatrician", "severe lip lacerations", "portion", "tongue appearing to", "bitten", "missing portions", "fingers", "right hand", "family history", "notable", "two similar cases", "male cousins", "mother's side", "urinalysis revealed", "high level", "uric acid", "following", "mode of inheritance", "disorder"]}
{"question": "An asymptomatic 65-year-old woman is found to have T-score of -2.6 SD on routine bone mineral density screening. She has a 10-year history of hypertension and an esophageal stricture due to severe gastroesophageal reflux disease. She was diagnosed with endometrial hyperplasia 20 years ago and treated with medroxyprogesterone. Menarche started at 11 years of age and her last menstrual period was 8 years ago. Her last mammography and PAP smear 6 months ago showed no abnormalities. Her mother died of breast cancer at the age of 45 years. The patient does not have any children. Current medications include lansoprazole and hydrochlorothiazide. Her blood pressure is 135/85 mm Hg. Physical examination shows no abnormalities. Treatment is begun with a drug that prevents further bone resorption and reduces her risk of developing breast cancer. This drug puts her at an increased risk of which of the following adverse effects?", "answer": "Deep vein thrombosis\n\"", "options": {"A": "Skin infections", "B": "Osteosarcoma", "C": "Hypercholesterolemia", "D": "Deep vein thrombosis\n\""}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["asymptomatic 65 year old woman", "found to", "T-score", "2", "SD", "routine bone mineral density screening", "a 10 year history of hypertension", "esophageal stricture due to severe gastroesophageal reflux disease", "diagnosed", "endometrial hyperplasia 20 years", "treated with medroxyprogesterone", "Menarche started", "years", "age", "last menstrual period", "years", "last mammography", "PAP smear", "months", "showed", "abnormalities", "mother died of breast cancer", "age", "years", "patient", "not", "children", "Current medications include lansoprazole", "hydrochlorothiazide", "blood pressure", "85 mm Hg", "Physical examination shows", "abnormalities", "Treatment", "begun", "drug", "prevents further bone resorption", "risk of", "breast cancer", "drug puts", "increased risk", "following adverse effects"]}
{"question": "A 28-year-old woman, gravida 1, para 0, at 20 weeks' gestation comes to the physician with her husband for a prenatal visit. Her pregnancy has been uncomplicated. They are planning to travel to Ethiopia next month to visit the husband's family. Medications include folic acid and an iron supplement. Vital signs are within the normal range. Abdominal examination shows a uterus that is consistent with a 20-week gestation. Which of the following drugs is most suitable for pre-exposure prophylaxis against malaria?", "answer": "Mefloquine", "options": {"A": "Doxycycline", "B": "Mefloquine", "C": "Chloroquine", "D": "Proguanil"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old woman", "gravida 1", "para 0", "20 weeks", "gestation", "physician", "husband", "prenatal visit", "pregnancy", "uncomplicated", "planning to travel to Ethiopia next month to visit", "husband's family", "Medications include folic acid", "iron supplement", "Vital signs", "normal range", "Abdominal examination shows", "uterus", "consistent with", "20 week gestation", "following drugs", "most suitable", "pre-exposure prophylaxis", "malaria"]}
{"question": "A 26-year-old man presents to the office complaining of persistent epigastric pain for the past 2 months. He states that his pain is worse a few hours after he eats. His father had similar symptoms. Past medical history is insignificant. He is a non-smoker and does not drink alcohol. The vital signs include blood pressure 120/90 mm Hg, heart rate 83/min, and temperature 37.0°C (98.6°F). Physical examination is insignificant except for mild epigastric tenderness. A metabolic panel reveals the following:\nSerum sodium 136 mEq/L\nSerum potassium 4.2 mEq/L\nCalcium 13.2 mg/dL\nBicarbonate 26 mEq/L\nUpper gastrointestinal endoscopy reveals multiple duodenal ulcers. Which of the following is the most likely diagnosis?", "answer": "MEN1", "options": {"A": "Gastroesophageal reflux disease", "B": "Gastric adenocarcinoma, intestinal type", "C": "VIPoma", "D": "MEN1"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old man presents", "office", "persistent epigastric pain", "past", "months", "states", "pain", "worse", "few hours", "eats", "father", "similar symptoms", "Past medical history", "non-smoker", "not drink alcohol", "vital signs include blood pressure", "90 mm Hg", "heart rate 83 min", "temperature", "98", "Physical examination", "mild epigastric tenderness", "metabolic panel reveals", "following", "Serum", "mEq", "potassium", "Calcium", "mg", "Bicarbonate", "Upper gastrointestinal endoscopy reveals multiple duodenal", "following", "most likely diagnosis"]}
{"question": "The parents of a 16-year-old boy with type 1 diabetes mellitus present requesting information about the drug, exenatide, an injectable drug that only needs to be administered once a week. The patient’s blood glucose levels have been difficult to control on his current insulin regimen due to poor adherence to recommended therapy, and he has had difficulty putting on weight despite eating copiously. The patient is afebrile and his vital signs are within normal limits. His body mass index (BMI) is 19 kg/m2. Which of the following best describes why the patient should not be switched to exenatide?", "answer": "Insulin production by the pancreas is insufficient for exenatide to be effective.", "options": {"A": "Insulin production by the pancreas is insufficient for exenatide to be effective.", "B": "Exenatide suppresses glucagon secretion, which increases the risk of hypoglycemia.", "C": "Suppression of appetite makes it even harder for him to gain weight.", "D": "Exenatide is contraindicated in children below 18 years."}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["parents", "year old boy", "type 1 diabetes mellitus present requesting information", "drug", "exenatide", "injectable drug", "only needs to", "administered once", "week", "patients blood glucose levels", "difficult", "control", "current insulin regimen due to poor adherence", "recommended therapy", "difficulty putting", "weight", "eating", "patient", "afebrile", "vital signs", "normal limits", "body mass index", "kg/m2", "following best", "patient", "not", "switched", "exenatide"]}
{"question": "A 79-year-old woman comes to the physician for the evaluation of a 2-month history of a non-productive cough and fatigue. During this period, she also has had a 4.5-kg (10-lb) weight loss and has become increasingly short of breath with mild exertion. She has congestive heart failure and hypertension. Three months ago, she was in India for 3 weeks to attend a family wedding. She worked as a seamstress in a textile factory for 50 years. She has smoked one pack of cigarettes daily for 47 years. Her current medications include enalapril, digoxin, isosorbide, spironolactone, and metoprolol. She appears thin. Her temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 25/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. There is dullness to percussion and decreased breath sounds over the right lung base. The remainder of the examination shows no abnormalities. Laboratory studies show a glucose level of 90 mg/dL, serum lactate dehydrogenase of 227 U/L, and serum protein of 6.3 g/dL. An x-ray of the chest shows nodular pleural lesions on the right side and a moderate-sized pleural effusion. Thoracentesis shows 250 ml of turbid fluid. Analysis of the pleural fluid aspirate shows:\nErythrocyte count 1/mm3\nLeukocyte count 4,000/mm3\nGlucose 59 mg/dl\nLactate dehydrogenase 248 U/L\nProtein 3.8 g/dL\nWhich of the following is the most likely underlying cause of this patient's effusion?\"", "answer": "Mesothelioma", "options": {"A": "Bronchial adenocarcinoma", "B": "Mesothelioma", "C": "Nephrotic syndrome", "D": "Congestive heart failure"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old woman", "physician", "evaluation", "month history", "non-productive cough", "fatigue", "period", "4.5 kg", "10", "weight loss", "short of breath", "mild exertion", "congestive heart failure", "hypertension", "Three months", "India", "3 weeks to attend", "family wedding", "worked", "textile factory", "50 years", "smoked one pack", "cigarettes daily", "years", "current medications include enalapril", "digoxin", "isosorbide", "spironolactone", "metoprolol", "appears thin", "temperature", "98", "pulse", "90 min", "respirations", "min", "blood pressure", "70 mm Hg", "Pulse oximetry", "room air shows", "oxygen saturation", "dullness", "percussion", "decreased breath sounds", "right lung base", "examination shows", "abnormalities", "Laboratory studies show", "glucose level", "90 mg/dL", "serum lactate dehydrogenase", "U L", "serum protein", "g/dL", "x-ray of", "chest shows nodular pleural lesions", "right side", "moderate sized pleural effusion", "Thoracentesis shows", "ml of turbid fluid", "Analysis", "pleural fluid aspirate shows", "Erythrocyte", "Leukocyte", "Glucose", "mg dl Lactate dehydrogenase", "L Protein", "dL", "following", "most likely underlying cause", "patient", "ffusion?"]}
{"question": "A 25-year-old woman comes to the physician because of irregular menstrual bleeding. Menses have occurred at 30- to 90-day intervals since menarche at the age of 12 years. Her last menstrual period was 6 weeks ago. She is sexually active with her husband and they do not use condoms. There is no personal or family history of serious illness. She is 170 cm (5 ft 7 in) tall and weighs 73 kg (161 lb); BMI is 25.3 kg/m2. Her vital signs are within normal limits. Examination shows oily skin and severe acne on the face. There is dark hair on the upper lip and around both nipples. Laboratory studies show:\nDehydroepiandrosterone sulfate 6.2 μg/mL (N=0.5–5.4)\nFollicle-stimulating hormone 20 mIU/mL\nLuteinizing hormone 160 mIU/mL\nTestosterone 4.1 nmol/L (N < 3.5)\nA urine pregnancy test is negative. Which of the following tests is the most appropriate next step in screening for comorbidities in this patient?\"", "answer": "Blood glucose and cholesterol level measurements", "options": {"A": "17-hydroxyprogesterone and cortisol level measurements", "B": "CA-125 level measurement", "C": "Blood glucose and cholesterol level measurements", "D": "TSH and T4 level measurements"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old woman", "physician", "irregular menstrual bleeding", "Menses", "occurred", "30", "90 day intervals", "menarche at", "age", "years", "last menstrual period", "weeks", "sexually active", "husband", "not use condoms", "personal", "family history", "serious illness", "5 ft", "tall", "kg", "BMI", "kg/m2", "vital signs", "normal limits", "Examination shows oily skin", "severe acne", "face", "dark hair", "upper lip", "nipples", "Laboratory studies show", "Dehydroepiandrosterone sulfate", "g/mL", "N 0 4", "Follicle-stimulating hormone 20 mIU/mL Luteinizing hormone", "Testosterone", "nmol/L", "N", "3.5", "urine pregnancy test", "negative", "following tests", "most appropriate next step", "screening", "comorbidities", "patient"]}
{"question": "A 51-year-old woman goes to respiratory function testing in order to evaluate her shortness of breath. She recently joined a walking program with her friends in order to lose weight; however, she noticed that she was not able to keep up with her friends during the program. She has a 60-pack-year history of smoking as well as hypertension well-controlled on medication. The following represent the parameters for this patient's respiratory anatomy and function:\n\nVital capacity (VC): 5,000 mL\nInspiratory reserve volume (IRV): 2,500 mL\nFunctional reserve capacity (FRC): 2,700 mL\nResidual volume (RV): 1,000 mL\nUpper airway volume: 100 mL\nConducting airway volume: 125 mL\n\nInspired CO2 pressure (PiCO2): 1 mmHg\nArterial CO2 pressure (PaCO2): 50 mmHg\nExpired CO2 pressure (PeCO2): 20 mmHg\n\nWhich of the following best represents the total volume of gas in this patient's airways and lungs that does not participate in gas exchange?", "answer": "480 mL", "options": {"A": "480 mL", "B": "600 mL", "C": "800 mL", "D": "1200 mL"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman goes", "respiratory function testing", "order to evaluate", "shortness of breath", "recently", "walking program", "friends", "order to", "weight", "not able to keep", "friends", "program", "60 pack-year history of smoking", "hypertension well-controlled", "medication", "following represent", "parameters", "patient's respiratory anatomy", "function", "Vital capacity", "5", "mL Inspiratory reserve volume", "2 500 mL Functional reserve capacity", "2 700 mL Residual volume", "1", "mL Upper", "100 mL Conducting airway volume", "mL", "Inspired CO2 pressure", "1 mmHg Arterial CO2 pressure", "50 mmHg Expired CO2 pressure", "20 mmHg", "following best represents", "total", "gas", "patient's airways", "lungs", "not", "gas exchange"]}
{"question": "A 44-year-old woman comes to the physician because of a 6-month history of fatigue, intermittent fever, a 4.0-kg (8.8-lb) weight loss, and a progressive, non-productive cough. She does not smoke. Physical examination shows mild wheezing over bilateral lung fields and enlarged supraclavicular and cervical lymph nodes. A CT scan of the chest is shown. A biopsy specimen of a cervical lymph node shows organized epithelioid histiocytes and multinucleated giant cells without focal necrosis. The initial treatment of this patient's condition should include which of the following drugs?", "answer": "Prednisone", "options": {"A": "Cisplatin", "B": "Lamivudine", "C": "Isoniazid", "D": "Prednisone"}, "meta_info": "step1", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "month history", "fatigue", "intermittent fever", "4 0 kg", "8.8", "weight loss", "progressive", "non-productive cough", "not smoke", "Physical examination shows mild wheezing", "bilateral lung fields", "enlarged supraclavicular", "cervical lymph nodes", "CT scan of", "chest", "shown", "biopsy specimen of", "cervical lymph node shows organized", "histiocytes", "multinucleated giant cells", "focal necrosis", "initial treatment", "patient's", "include", "following drugs"]}
{"question": "A 55-year-old nulligravid woman comes to the physician because of a 3-day history of heavy vaginal bleeding, requiring more than 5 pads per day. Menopause occurred 1 year ago. She attained menarche at 10 years of age. She has a history of hypothyroidism and type 2 diabetes mellitus. She has smoked 1 pack of cigarettes daily for 20 years but quit 5 years ago. Current medications include levothyroxine and metformin. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb); BMI is 32 kg/m2. Physical examination shows mild vaginal atrophy and a normal cervix. The uterus and adnexa are nontender to palpation. Transvaginal ultrasonography shows an endometrial thickness of 6 mm. Endometrial biopsy shows non-invasive proliferation of endometrial glands with no nuclear or cytological atypia. Which of the following is the most appropriate next step in management?", "answer": "Progestin therapy", "options": {"A": "Total hysterectomy", "B": "Estrogen vaginal cream", "C": "Reassurance and follow-up", "D": "Progestin therapy"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["55 year old nulligravid woman", "physician", "3 history", "heavy vaginal bleeding", "more", "pads", "day", "Menopause occurred 1 year", "menarche at 10 years", "age", "history of hypothyroidism", "type 2 diabetes mellitus", "smoked 1 pack", "cigarettes daily", "20 years", "quit", "years", "Current medications include levothyroxine", "metformin", "5 ft 5", "tall", "kg", "BMI", "kg/m2", "Physical examination shows mild vaginal atrophy", "normal cervix", "uterus", "adnexa", "nontender", "palpation", "Transvaginal ultrasonography shows", "endometrial thickness of", "mm", "biopsy shows non-invasive proliferation", "endometrial glands", "nuclear", "cytological atypia", "following", "most appropriate next step", "management"]}
{"question": "A 37-year-old woman with an HIV infection comes to the physician for a follow-up examination. Six months ago, combined antiretroviral therapy consisting of dolutegravir, tenofovir, and emtricitabine was initiated. Laboratory studies show a decrease in the CD4 count and an increase in the viral load despite ongoing treatment. The patient is switched to a new treatment regimen, including a drug that acts by preventing viral DNA synthesis without undergoing intracellular phosphorylation. Which of the following is the most likely drug?", "answer": "Efavirenz", "options": {"A": "Efavirenz", "B": "Ritonavir", "C": "Raltegravir", "D": "Lamivudine\n\""}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old woman", "HIV infection", "physician", "follow-up examination", "Six months", "combined antiretroviral consisting", "dolutegravir", "tenofovir", "emtricitabine", "initiated", "Laboratory studies show", "decrease", "CD4 count", "increase", "viral load", "ongoing treatment", "patient", "switched", "new treatment regimen", "including", "drug", "acts", "preventing viral DNA synthesis", "intracellular phosphorylation", "following", "most likely drug"]}
{"question": "A 14-year-old girl presents with sudden drooping of the right side of her face with drooling and excessive tearing. The patient’s mother says that the patient was recently in northern Maine and spent most of her time during the trip outdoors. Physical examination reveals a slight asymmetry of the facial muscles with an inability to whistle or close the right eye. A circular red rash with central clearing is present on the trunk. There is also decreased taste sensation. Which of the following most likely transmitted the organism responsible for this patient’s illness?", "answer": "Ixodes scapularis", "options": {"A": "Ixodes scapularis", "B": "Tsetse fly", "C": "Culicidae", "D": "Anopheles"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["year old girl presents", "sudden", "of", "right side", "face", "drooling", "excessive tearing", "patients mother", "patient", "recently", "northern Maine", "spent most of", "time", "trip outdoors", "Physical examination reveals", "slight asymmetry", "facial", "whistle", "close", "right eye", "circular red rash", "central clearing", "present", "trunk", "decreased taste sensation", "following most likely transmitted", "organism responsible", "patients illness"]}
{"question": "A 66-year-old man with high blood pressure, high cholesterol, and diabetes presents to the clinic with elevated liver function tests from baseline. He has a blood pressure of 136/92 mm Hg and a heart rate of 69/min. On physical examination, his heart sounds are regular and lung sounds are clear. Current medications include simvastatin, metformin, fenofibrate, hydrochlorothiazide, aspirin, glyburide, and lisinopril. Of these medications, which could contribute to the patient’s transaminitis?", "answer": "Simvastatin", "options": {"A": "Metformin", "B": "Simvastatin", "C": "Glyburide", "D": "Lisinopril"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["66 year old man", "high blood pressure", "high cholesterol", "diabetes presents", "clinic", "elevated liver function tests", "baseline", "blood pressure", "mm Hg", "heart rate", "69 min", "physical examination", "heart sounds", "regular", "lung sounds", "clear", "Current medications include simvastatin", "metformin", "fenofibrate", "hydrochlorothiazide", "aspirin", "glyburide", "lisinopril", "medications", "contribute", "patients transaminitis"]}
{"question": "A 7 -day-old newborn boy presents to the emergency department with a history of fever, irritability, and generalized erythema. During the first 2 days of clinical manifestations, the parents of the child tried to control the symptoms using acetaminophen; however, the newborn continued to be ill, and blisters were noticeable around the buttocks, hands, and feet. During the physical examination, the vital signs include body temperature 39.0°C (102.3°F), heart rate 130/min, and respiratory rate 45/min. Ears, nose, and oral mucosa preserved their integrity, while the skin presents with diffuse blanching erythema and flaccid blisters with a positive Nikolsky’s sign. What is the most likely diagnosis in this patient?", "answer": "Scalded skin syndrome", "options": {"A": "Scarlet fever", "B": "Scalded skin syndrome", "C": "Impetigo", "D": "Pyoderma"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["day old newborn boy presents", "emergency department", "history", "fever", "irritability", "generalized erythema", "first 2 days of clinical manifestations", "parents of", "child", "to control", "symptoms using acetaminophen", "newborn continued to", "ill", "blisters", "buttocks", "hands", "feet", "physical examination", "vital signs include body temperature", "heart rate", "min", "respiratory rate", "min", "Ears", "nose", "oral mucosa preserved", "integrity", "skin presents", "diffuse blanching erythema", "flaccid blisters", "positive Nikolskys sign", "most likely diagnosis", "patient"]}
{"question": "A 60-year-old woman presents to the outpatient clinic complaining of severe vulvar itching that has been gradually worsening for the past year. She mentions that she has tried over-the-counter lubricants, but lubricants do not seem to provide substantial relief. Her medical history is remarkable for diet-controlled type 2 diabetes mellitus and hypertension treated with hydrochlorothiazide. Menopause occurred at 52 years of age. She has been sexually active with her husband until recently and reports severe pain during vaginal intercourse. The physical examination reveals dry, thin, white plaque-like lesions in the vulvar area with atrophy of the labia minora. The clitoris appears retracted. The perianal skin appears pale and wrinkled. Which of the following is the most likely diagnosis?", "answer": "Lichen sclerosus", "options": {"A": "Squamous cell hyperplasia", "B": "Lichen sclerosus", "C": "Squamous cell carcinoma of the vulva", "D": "Lichen planus"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["60 year old woman presents", "outpatient clinic", "severe vulvar itching", "worsening", "past year", "over-the-counter lubricants", "lubricants", "not", "to provide", "relief", "medical history", "diet-controlled type 2 diabetes mellitus", "hypertension treated with hydrochlorothiazide", "Menopause occurred", "years", "age", "sexually active", "husband", "recently", "reports severe pain", "vaginal intercourse", "physical examination reveals dry", "thin", "white plaque-like lesions", "vulvar area", "atrophy", "labia minora", "clitoris appears retracted", "perianal skin appears pale", "wrinkled", "following", "most likely diagnosis"]}
{"question": "A 50-year-old woman with Systemic Lupus Erythematosus (SLE) presents to your clinic with complaints of left eye pain and reduced vision. She notes that she was in her usual state of health until 3 days prior to presentation when she noticed some mild tenderness around her left eye, unrelieved by any pain relievers. This morning when she woke up she was unable to see out of her left eye and made an appointment to come see you. Other than SLE, her medical history is unremarkable. She has had no additional symptoms other than pain and vision loss. Her vital signs are all within normal limits. On exam, she has no vision in her left eye, but 20/30 visual acuity in her right eye. When you shine a light in her left eye there is no response. What response would you expect when you shine a light in her right eye?", "answer": "Bilateral miosis", "options": {"A": "Bilateral miosis", "B": "Miosis of the right eye only", "C": "Miosis of the left eye only", "D": "Mydriasis of the left eye"}, "meta_info": "step1", "answer_idx": "A", "metamap_phrases": ["50 year old woman", "Systemic Lupus Erythematosus", "presents", "clinic", "complaints of left eye pain", "reduced vision", "notes", "usual state of health", "3 days prior to presentation", "mild tenderness", "left", "pain relievers", "morning", "woke up", "unable to see out", "left eye", "made", "appointment to", "see", "SLE", "medical history", "unremarkable", "additional symptoms other", "pain", "vision loss", "vital signs", "normal limits", "exam", "vision", "left", "20/30 visual acuity", "right eye", "light", "left eye", "response", "response", "light", "right eye"]}
{"question": "A 25-year-old woman presents to the emergency department with abdominal pain. She states that she was walking up the stairs at work when she felt sudden and severe abdominal pain followed by nausea and vomiting. Her past medical history is non-contributory and she is not currently taking any medications. Her temperature is 99.7°F (37.6°C), blood pressure is 122/78 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for an absence of abdominal tenderness, a left adnexal mass, and left adnexal tenderness. A transvaginal ultrasound demonstrates free fluid surrounding the ovary with edema and the presence of doppler flow. A urinary pregnancy test is negative. The patient's symptoms persisted after ibuprofen and acetaminophen. Which of the following is the best next step in management?", "answer": "Laparoscopy", "options": {"A": "Laparoscopy", "B": "Laparotomy", "C": "MRI of the pelvis", "D": "Observation and serial abdominal exams"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman presents", "emergency department", "abdominal pain", "states", "walking", "stairs", "work", "felt sudden", "severe abdominal followed by nausea", "vomiting", "past medical history", "non contributory", "not currently taking", "medications", "temperature", "99", "blood pressure", "mmHg", "pulse", "min", "respirations", "min", "oxygen saturation", "98", "room air", "Physical exam", "notable", "absence of abdominal tenderness", "left adnexal mass", "left adnexal tenderness", "transvaginal ultrasound demonstrates free fluid surrounding", "ovary", "edema", "presence", "doppler flow", "urinary pregnancy test", "negative", "patient's symptoms", "ibuprofen", "acetaminophen", "following", "best next step", "management"]}
{"question": "A 65-year-old man comes to the physician because of progressively worsening fatigue for 6 months. During this time, he has also had shortness of breath and palpitations on exertion. He has noticed blood in his stools on three separate occasions in the past 4 months. He has type 2 diabetes mellitus and end-stage renal disease. He drinks two to four beers daily. He does not smoke. His pulse is 95/min and blood pressure is 120/70 mm Hg. Examination shows pale conjunctivae. The abdomen is soft with no organomegaly. Rectal examination is unremarkable. His hemoglobin concentration is 7.2 g/dL, hematocrit is 32%, and mean corpuscular volume is 68 μm3. Which of the following is the most likely underlying cause of this patient's bleeding?", "answer": "Arteriovenous malformation in the colonic wall", "options": {"A": "Inflammation in an outpouching of the colonic wall", "B": "Symptomatic enlargement of hemorrhoidal plexus", "C": "Chronic mucosal and submucosal inflammation of the colon", "D": "Arteriovenous malformation in the colonic wall"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["65 year old man", "physician", "worsening fatigue", "months", "time", "shortness of breath", "palpitations", "exertion", "blood in", "stools", "three separate occasions", "past", "months", "type 2 diabetes mellitus", "end-stage renal disease", "drinks two", "four beers daily", "not smoke", "pulse", "95 min", "blood pressure", "70 mm Hg", "Examination shows pale conjunctivae", "abdomen", "soft", "organomegaly", "Rectal examination", "unremarkable", "hemoglobin concentration", "7.2 g/dL", "hematocrit", "mean corpuscular volume", "68 m3", "following", "most likely underlying cause", "patient's bleeding"]}
{"question": "A 24-year-old woman comes to the emergency department with her boyfriend 2 hours after an episode of loss of consciousness. She was seated and was being tattooed on her right upper flank when she became diaphoretic, pale, and passed out. According to her boyfriend, the patient slipped to the floor and her arms and legs moved in a jerky fashion for a few seconds. She regained consciousness within half a minute and was alert and fully oriented immediately. She has no history of serious illness. She works as an event manager and has had more stress than usual due to a recent concert tour. She appears well. Her temperature is 37°C (98.4°F), pulse is 68/min, respirations are 16/min, and blood pressure is 120/72 mm Hg. Her cardiopulmonary examination shows no abnormalities. Neurologic examination shows no focal findings. An ECG shows an incomplete right bundle branch block. Which of the following is the most likely diagnosis?", "answer": "Vasovagal syncope", "options": {"A": "Vasovagal syncope", "B": "Orthostatic syncope", "C": "Cardiac arrhythmia", "D": "Cardiac structural abnormality\n\""}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["year old woman", "emergency department", "boyfriend", "hours", "episode of loss", "consciousness", "seated", "tattooed", "right flank", "diaphoretic", "pale", "passed out", "boyfriend", "patient slipped", "floor", "arms", "legs moved", "jerky", "few seconds", "regained consciousness", "half", "minute", "alert", "oriented immediately", "history", "serious illness", "works", "event manager", "more stress", "usual", "recent", "tour", "appears well", "temperature", "98 4F", "pulse", "68 min", "respirations", "min", "blood pressure", "72 mm Hg", "cardiopulmonary examination shows", "abnormalities", "Neurologic examination shows", "focal findings", "ECG shows", "incomplete right bundle branch block", "following", "most likely diagnosis"]}
{"question": "A 15-year-old boy is brought to the emergency department 1 hour after falling from his bicycle. The boy was racing with his cousin when he lost control and fell onto his right side. He has nausea and severe pain in the right shoulder. He is in acute distress. His temperature is 37°C (98.6°F), pulse is 85/min, respirations are 15/min, and blood pressure is 135/85 mm Hg. Examination shows swelling and tenderness over the right clavicle and pain exacerbated by movement; range of motion is limited. The skin over the clavicle is intact. The radial pulse in the right arm is intact. Sensory examination of the right upper limb shows no abnormalities. An x‑ray of the chest is shown. Which of the following is the most appropriate next step in management for this patient's shoulder?", "answer": "Apply a simple shoulder sling", "options": {"A": "Perform tension banding", "B": "Apply a simple shoulder sling", "C": "Obtain an MRI of the right shoulder", "D": "Perform arteriography"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["year old boy", "brought", "emergency department", "hour", "falling", "bicycle", "boy", "racing", "cousin", "lost control", "fell", "right side", "nausea", "severe pain in", "right shoulder", "acute distress", "temperature", "98", "pulse", "85 min", "respirations", "min", "blood pressure", "85 mm Hg", "Examination shows swelling", "tenderness", "right", "pain exacerbated", "movement", "range of motion", "limited", "skin", "clavicle", "intact", "radial pulse", "right arm", "intact", "Sensory examination of", "right upper limb shows", "abnormalities", "xray of", "chest", "shown", "following", "most appropriate next step", "management", "patient's shoulder"]}
{"question": "A 51-year-old man is brought to the physician by his wife because of a 3-week history of abnormal behavior. His wife reports he has been preoccupied with gambling at the local casino. He becomes restless and irritable when his wife attempts to restrict his gambling. Four months ago, he was diagnosed with Parkinson disease and treatment was initiated. Which of the following best describes the mechanism of action of the drug that was most likely prescribed for this patient?", "answer": "Direct activation of dopamine receptors", "options": {"A": "Peripheral inhibition of DOPA decarboxylase", "B": "Direct activation of dopamine receptors", "C": "Selective inhibition of monoamine oxidase B", "D": "Inhibition of catechol-O-methyl transferase"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["year old man", "brought", "physician", "wife", "week history", "abnormal behavior", "wife reports", "gambling", "local casino", "restless", "irritable", "wife attempts to restrict", "gambling", "Four months", "diagnosed", "Parkinson disease", "treatment", "initiated", "following best", "mechanism of action", "drug", "most likely prescribed", "patient"]}
{"question": "A 55-year-old woman with no significant past medical history presents to her primary care doctor with fever, fatigue, and bleeding gums for the past 3 days. She denies any sick contacts. Her temperature is 101°F (38.3°C), blood pressure is 110/70 mmHg, pulse is 96/min, and respirations are 15/min. Physical exam reveals several oral mucosal petechiae, bleeding gums, bilateral submandibular lymphadenopathy, and hepatosplenomegaly. Initial laboratory workup shows the following:\n\nLeukocyte count and differential:\nLeukocyte count: 6,600/mm^3\nSegmented neutrophils: 60%\nBands: 20%\nEosinophils: 9%\nBasophils: 1%\nLymphocytes: 0%\nMonocytes: 10%\nPlatelet count: 99,000/mm^3\n\nHemoglobin: 8.1 g/dL\nHematocrit: 25%\n\nProthrombin time: 25 sec\nPartial thromboplastin time: 50 sec\nInternational normalized ratio: 1.6\nD-dimer: 2,000 µg/mL\nFibrinogen: 99 mg/dL\n\nA bone marrow biopsy demonstrates 34% myeloblasts with Auer rods that are myeloperoxidase positive. What is best treatment option?", "answer": "Retinoic acid", "options": {"A": "Ascorbic acid", "B": "Fresh frozen plasma", "C": "Retinoic acid", "D": "Zoledronic acid"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["55 year old woman", "significant past medical history presents", "primary care doctor", "fever", "fatigue", "bleeding gums", "past 3 days", "denies", "sick contacts", "temperature", "3C", "blood pressure", "70 mmHg", "pulse", "96 min", "respirations", "min", "Physical exam reveals several oral mucosal petechiae", "bleeding gums", "bilateral submandibular lymphadenopathy", "hepatosplenomegaly", "Initial laboratory workup shows", "following", "Leukocyte count", "differential", "Leukocyte count", "6 600 mm 3 Segmented neutrophils", "60", "Bands", "20", "Eosinophils", "Basophils", "1", "Lymphocytes", "0", "Monocytes", "10", "Platelet count", "99", "mm", "Hemoglobin", "8.1 g/dL Hematocrit", "Prothrombin time", "sec Partial thromboplastin time", "50 sec International normalized ratio", "1.6", "dimer", "2", "g/mL Fibrinogen", "99 mg/dL", "bone marrow biopsy demonstrates", "myeloblasts", "Auer rods", "myeloperoxidase positive", "best treatment option"]}
{"question": "A 30-year-old man presents to the emergency room complaining of malaise. Two hours prior to presentation, he developed muscle cramps and nausea. He has had 3 episodes of non-bloody watery stools since his symptoms started. He reports that he has experienced similar symptoms multiple times over the past 5 years since he started working at his local zoo as a reptilian caretaker. His medical history is unremarkable. He takes fish oil and a multivitamin daily. His temperature is 101°F (38.3°C), blood pressure is 130/90 mmHg, pulse is 90/min, and respirations are 17/min. On exam, he demonstrates sensitivity to bright light. He is tired-appearing but alert and fully oriented. A stool sample and culture demonstrates abundant non-lactose fermenting, oxidase-negative, and H2S-producing gram-negative bacilli. The pathogen responsible for this patient’s condition relies on a virulence factor with which of the following mechanisms of action?", "answer": "Blocking antibody attack on the O antigen", "options": {"A": "ADP ribosylation of elongation factor 2", "B": "Blocking antibody attack on the O antigen", "C": "Cleaving immunoglobulin A molecules", "D": "Cleaving lecithin"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["30 year old man presents", "emergency room", "malaise", "Two hours", "presentation", "muscle cramps", "nausea", "3 episodes of non bloody watery", "symptoms started", "reports", "similar symptoms multiple times", "past", "years", "started working", "local", "caretaker", "medical history", "unremarkable", "takes fish oil", "multivitamin daily", "temperature", "3C", "blood pressure", "90 mmHg", "pulse", "90 min", "respirations", "min", "exam", "demonstrates sensitivity to bright light", "tired appearing", "alert", "oriented", "stool sample", "culture demonstrates abundant non lactose", "oxidase negative", "gram-negative bacilli", "pathogen responsible", "patients condition", "virulence factor", "of", "following mechanisms", "action"]}
{"question": "A 62-year-old man is brought to the physician by his wife because of difficulties walking for the past year. He has had multiple falls over the past 4 months. Over the past 6 months, he has had progressive urinary urgency and now wears an adult diaper as is not always able to control the urge to void. His appetite has also decreased in this time period. He used to drive, but his wife convinced him to stop after she noticed that he was becoming increasingly inattentive while driving. He has type 2 diabetes mellitus and hypertension. Current medications include ramipril and metformin. His temperature is 37.1C (98.8F), pulse is 90/min and blood pressure is 132/88 mm Hg. Examination shows a broad-based gait with slow and short steps. Neurologic examination shows no focal findings. On mental status examination, he is oriented to person and place but not to time. Attention and concentration are impaired. He recalls only one of three objects after 5 minutes. Which of the following is the most appropriate therapy for this patient's symptoms?", "answer": "Ventricular shunting", "options": {"A": "Ventricular shunting", "B": "Acetazolamide therapy", "C": "Temporal lobectomy", "D": "Donepezil therapy"}, "meta_info": "step2&3", "answer_idx": "A", "metamap_phrases": ["62 year old man", "brought", "physician", "wife", "difficulties walking", "past year", "multiple falls", "past", "months", "past 6 months", "progressive urinary urgency", "now", "adult diaper as", "not always able to control", "void", "appetite", "decreased", "time period", "used to drive", "wife", "to stop", "inattentive", "driving", "type 2 diabetes mellitus", "hypertension", "Current medications include ramipril", "metformin", "temperature", "98", "pulse", "90 min", "blood pressure", "88 mm Hg", "Examination shows", "broad-based gait", "slow", "short steps", "Neurologic examination shows", "focal findings", "mental", "oriented to person", "place", "not", "time", "Attention", "concentration", "impaired", "recalls only one", "three objects", "5 minutes", "following", "most appropriate therapy", "patient's symptoms"]}
{"question": "A 40-year-old woman with Down syndrome comes to the physician for the evaluation of fatigue, progressive clumsiness when using her hands, and difficulty walking for 3 months. During this period, the patient has had several episodes of dizziness as well as double vision. She also reports that she has lost control of her bladder on several occasions lately. She has not had any trauma or weight changes. She lives with her sister and works as a cashier in a local retail store. She takes no medications. Her vital signs are within normal limits. On mental status examination, she is oriented to person and place only. There is moderate weakness of the upper and lower extremities. Sensory examination shows no abnormalities. Deep tendon reflexes are 3+ bilaterally. Babinski's sign is present bilaterally. Which of the following would most likely improve this patient's symptoms?", "answer": "Surgical fusion of C1/C2", "options": {"A": "Administration of botulism antitoxin", "B": "Surgical fusion of C1/C2", "C": "Administration of methylprednisolone", "D": "Administration of pyridostigmine\n\""}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["40 year old woman", "Down syndrome", "physician", "evaluation", "fatigue", "progressive clumsiness", "using", "hands", "difficulty walking", "months", "period", "patient", "several episodes of dizziness", "double vision", "reports", "lost control", "bladder", "several occasions", "not", "trauma", "weight changes", "lives", "sister", "works", "local retail store", "takes", "medications", "vital signs", "normal limits", "mental", "oriented to person", "place only", "moderate weakness", "upper", "lower extremities", "Sensory examination shows", "abnormalities", "Deep tendon reflexes", "3", "Babinski's sign", "present", "following", "most likely", "patient's symptoms"]}
{"question": "A 74-year-old woman with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus is brought to her primary care doctor by her son who is concerned about the patient's ability to manage her activities of daily living. She has been living alone since her husband passed away 2 years ago. She has remained an active member of her retirement community's wine club; however, she stopped attending the meetings 3 weeks ago. She is generally able to her maintain her house, but her house appears more disorganized over the past 2 weeks. She generally drives short distances but avoids driving long distances as she occasionally gets lost when navigating new areas. She feels like her balance is getting worse, but she has not fallen. She has noticed increased urinary urgency over the past 8 months and has had 2 episodes of incontinence. Despite these changes, she reports feeling well. She drinks 4-6 glasses of wine per day. She was started on multiple medications for worsening anxiety by her psychiatrist 1 month ago. Her BMI is 31 kg/m^2. Her temperature is 99.8°F (37.7°C), blood pressure is 115/65 mmHg, pulse is 95/min, and respirations are 17/min. On examination, she is oriented to person and time but not place or situation. She does not seem to recognize her doctor despite knowing him for many years. She becomes somnolent intermittently throughout the interview. She can recall 0/3 words after 5 minutes. She has a low-frequency tremor in her right arm that increases in severity with deliberate movement. Which of the following is the most likely diagnosis in this patient?", "answer": "Delirium", "options": {"A": "Alzheimer dementia", "B": "Delirium", "C": "Lewy body dementia", "D": "Normal pressure hydrocephalus"}, "meta_info": "step1", "answer_idx": "B", "metamap_phrases": ["74 year old woman", "history of hypertension", "hyperlipidemia", "type 2 diabetes mellitus", "brought", "primary care doctor", "son", "concerned", "patient's ability to", "activities of daily living", "living alone", "husband passed", "years", "active member", "retirement community's wine club", "stopped attending", "meetings", "weeks", "able", "maintain", "house", "house appears more", "past 2 weeks", "drives short distances", "driving long distances", "occasionally gets lost", "new areas", "feels", "balance", "getting worse", "not fallen", "increased urinary urgency", "past", "months", "2 episodes of incontinence", "changes", "reports feeling well", "drinks 4-6 glasses", "wine", "day", "started", "multiple medications", "worsening anxiety", "psychiatrist", "month", "BMI", "31 kg/m", "temperature", "99", "blood pressure", "65 mmHg", "pulse", "95 min", "respirations", "min", "examination", "oriented to person", "time", "not place", "not", "to", "doctor", "years", "somnolent", "interview", "recall 0/3 words", "5 minutes", "low-frequency tremor", "right arm", "increases", "severity", "movement", "following", "most likely diagnosis", "patient"]}
{"question": "A 45-year-old male with a history of diabetes and poorly controlled hypertension presents to his primary care physician for an annual check-up. He reports that he feels well and has no complaints. He takes enalapril and metformin. His temperature is 98.8°F (37.1°C), blood pressure is 155/90 mmHg, pulse is 80/min, and respirations are 16/min. His physician adds another anti-hypertensive medication to the patient’s regimen. One month later, the patient returns to the physician complaining of new onset lower extremity swelling. Which of the following medications was likely prescribed to this patient?", "answer": "Nifedipine", "options": {"A": "Metoprolol", "B": "Verapamil", "C": "Nifedipine", "D": "Hydrochlorthiazide"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old male", "history", "diabetes", "poorly controlled hypertension presents", "primary care physician", "annual check-up", "reports", "feels well", "complaints", "takes enalapril", "metformin", "temperature", "98", "blood pressure", "90 mmHg", "pulse", "80 min", "respirations", "min", "physician adds", "anti-hypertensive medication", "patients regimen", "One month later", "patient returns", "physician", "new onset lower extremity swelling", "following medications", "likely prescribed", "patient"]}
{"question": "A 29-year-old woman comes to the physician with high-grade fever, headache, and muscle pain. A week ago, she returned from India, where she was working with an NGO to build houses in rural areas. The patient took one dose of chloroquine one week before her trip. She also took a further dose during her trip. She has no history of a serious illness. Her temperature is 39.3°C (102.7°F), pulse is 102/min, respirations are 22/min, and blood pressure is 112/78 mm Hg. Physical examination shows jaundice. The abdomen is soft and nontender. The remainder of the examination shows no abnormalities. Her hemoglobin concentration is 10 g/dL and a blood smear shows fragmented erythrocytes and occasional ring-shaped inclusion bodies within erythrocytes. Which of the following is the most likely cause of infection in this patient?", "answer": "Plasmodium falciparum", "options": {"A": "Plasmodium ovale", "B": "Plasmodium falciparum", "C": "Chikungunya virus", "D": "Hepatitis A virus"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["29 year old woman", "physician", "high-grade fever", "headache", "muscle pain", "week", "returned", "India", "working", "build houses", "rural areas", "patient took one dose", "chloroquine", "week", "trip", "took", "further dose", "trip", "history", "serious illness", "temperature", "3C", "pulse", "min", "respirations", "min", "blood pressure", "mm Hg", "Physical examination shows jaundice", "abdomen", "soft", "nontender", "examination shows", "abnormalities", "hemoglobin concentration", "10 g/dL", "blood smear shows fragmented erythrocytes", "occasional ring-shaped inclusion bodies", "erythrocytes", "following", "most likely cause", "infection", "patient"]}
{"question": "A 39-year-old woman presents to the clinic for her annual physical. Although she feels generally healthy she has noticed gaining about 9 kg (20 lb) over the last year. She eats a healthy, varied diet and exercises at the gym 4 days a week, including 20 minutes of aerobic exercise. On further questioning, she has also noted fatigue and constipation. She denies shortness of breath, chest pain, lightheadedness, or blood in her stool. At the clinic, the vital signs include: pulse 52/min, blood pressure 110/72 mm Hg, and oxygen saturation 99% on room air. The physical exam is notable only for slightly dry skin. The complete blood count (CBC) is within normal limits. Which of the following laboratory values is most likely elevated in this patient?", "answer": "Thyroid-stimulating hormone (TSH)", "options": {"A": "Glucose", "B": "Triiodothyronine (T3)", "C": "Thyroxine (T4)", "D": "Thyroid-stimulating hormone (TSH)"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman presents", "clinic", "annual physical", "feels", "healthy", "gaining", "kg", "20", "last year", "eats", "healthy", "varied diet", "exercises", "4 days", "week", "including 20 minutes", "aerobic exercise", "further questioning", "noted fatigue", "constipation", "denies shortness of breath", "chest pain", "lightheadedness", "blood in", "stool", "clinic", "vital signs include", "pulse", "min", "blood pressure", "72 mm Hg", "oxygen 99", "room air", "physical exam", "notable only", "slightly dry skin", "complete blood count", "CBC", "normal limits", "following laboratory values", "most likely elevated", "patient"]}
{"question": "A 38-year-old woman comes to the physician because of persistent diarrhea and fatigue for 1 month. She has had up to 12 watery stools per day. Sometimes she awakens at night because she has to defecate. She has abdominal bloating and cramps. She has had a 2-kg weight loss in the past month. She returned from a trip to Costa Rica 7 weeks ago. She has a history of bronchial asthma and bulimia nervosa. She works as a nurse. She does not smoke and drinks 1–2 beers on the weekend. Current medications include fish oil, a multivitamin, and a salbutamol inhaler. Her temperature is 36.8°C (98.2°F), pulse is 65/min, and blood pressure is 100/75 mm Hg. Examination shows dry mucous membranes. Abdominal and rectal examinations are unremarkable. Laboratory studies show:\nHematocrit 46%\nLeukocyte Count 6,500/mm3\nPlatelet Count 220,000/mm3\nSerum\nNa+ 136 mEq/L\nK+ 3.2 mEq/L\nCl- 102 mEq/L\nHCO3- 33 mEq/L\nMg2+ 3.3 mEq/L\nUrea nitrogen 14 mg/dL\nCreatinine 0.8 mg/dL\nAbdominal ultrasound shows no abnormalities. Colonoscopy shows dark colored mucosa with interspersed white spots. Biopsies of colonic mucosa are obtained and sent for pathological evaluation. Which of the following is the most likely underlying cause of this patient's symptoms?\"", "answer": "Medication abuse", "options": {"A": "Celiac disease", "B": "Carcinoid tumor", "C": "VIPoma", "D": "Medication abuse"}, "meta_info": "step2&3", "answer_idx": "D", "metamap_phrases": ["year old woman", "physician", "persistent diarrhea", "fatigue", "month", "up to", "watery stools", "day", "Sometimes", "night", "abdominal bloating", "cramps", "2 kg weight loss", "past month", "returned", "trip", "Costa Rica", "weeks", "history of bronchial asthma", "bulimia nervosa", "works", "nurse", "not smoke", "drinks", "beers", "weekend", "Current medications include fish oil", "multivitamin", "salbutamol inhaler", "temperature", "36", "98", "pulse", "65 min", "blood pressure", "100 75 mm Hg", "Examination shows dry mucous membranes", "Abdominal", "rectal examinations", "unremarkable", "Laboratory studies show", "Hematocrit", "Leukocyte 6 500 mm3 Platelet Count", "Serum", "mEq", "HCO3", "Mg2", "mg dL Creatinine 0.8", "Abdominal ultrasound shows", "abnormalities", "Colonoscopy shows dark colored mucosa", "white spots", "Biopsies of colonic mucosa", "obtained", "sent", "pathological evaluation", "following", "most likely underlying cause", "patient", "ymptoms?"]}
{"question": "A 21-year-old college student comes to the physician because of daytime fatigue for 2 months. He has problems getting to sleep at night and frequently falls asleep during class. Recently he has started skipping classes altogether. He goes to bed between 11 p.m. and 1 a.m. but cannot fall asleep for 2–3 hours. When he wakes up at 8:30 a.m., he feels extremely drowsy, and he tries to overcome his fatigue by drinking 2–3 cups of coffee a day. He naps at various times during the afternoon, often for more than an hour. He stopped watching videos on his smartphone at night because of suggestions from his peers. He states that he has tried over-the-counter melatonin pills and exercising at 8 p.m. without success. He has no history of serious illness. He does not smoke. He drinks three to five beers on weekends. Physical examination shows no abnormalities. Which of the following is the most appropriate recommendation for this patient?", "answer": "Stop evening exercise", "options": {"A": "Trial of diphenhydramine", "B": "Stop evening exercise", "C": "Alcoholic beverage prior to bedtime", "D": "Scheduled afternoon naps"}, "meta_info": "step2&3", "answer_idx": "B", "metamap_phrases": ["21-year-old college student", "physician", "of daytime fatigue", "months", "problems getting to sleep", "night", "frequently falls asleep", "class", "Recently", "started skipping classes", "goes", "bed", "m", "1", "m", "fall asleep", "23 hours", "wakes up", "30", "m", "feels extremely drowsy", "to overcome", "fatigue", "drinking 23 cups", "coffee", "day", "naps", "various times", "afternoon", "often", "hour", "stopped watching videos", "smartphone", "night", "of suggestions", "peers", "states", "over-the-counter melatonin pills", "exercising", "8", "m", "success", "history", "serious illness", "not smoke", "drinks three", "five beers", "weekends", "Physical examination shows", "abnormalities", "following", "most appropriate recommendation", "patient"]}
{"question": "A 19-year-old man is brought to the physician by his mother because she is worried about his strange behavior. Over the past 3 years, he has been dressing all in black and wears a long black coat, even in the summer. The mother reports that her son has always had difficulties fitting in. He does not have any friends and spends most of his time in his room playing online games. He is anxious at college because he is uncomfortable around other people, and his academic performance is poor. Rather than doing his coursework, he spends most of his time reading up on paranormal phenomena, especially demons. He says that he has never seen any demons, but sometimes there are signs of their presence. For example, a breeze in an enclosed room is likely the “breath of a demon”. Mental status examination shows laborious speech. The patient avoids eye contact. Which of the following is the most likely diagnosis?", "answer": "Schizotypal personality disorder", "options": {"A": "Social anxiety disorder", "B": "Avoidant personality disorder", "C": "Schizotypal personality disorder", "D": "Schizophrenia"}, "meta_info": "step2&3", "answer_idx": "C", "metamap_phrases": ["year old man", "brought", "physician", "mother", "worried", "strange behavior", "past", "years", "dressing", "black", "long black coat", "summer", "mother reports", "son", "always", "difficulties fitting", "not", "friends", "spends most of", "time", "room playing", "games", "anxious", "college", "people", "academic performance", "poor", "spends most of", "time reading", "phenomena", "never seen", "sometimes", "signs", "presence", "example", "enclosed room", "likely", "breath", "Mental shows laborious speech", "patient", "eye contact", "following", "most likely diagnosis"]}
{"question": "A 79-year-old man presents to the office due to shortness of breath with moderate exertion and a slightly productive cough. He has a medical history of 25 years of heavy smoking. His vitals include: heart rate 89/min, respiratory rate 27/min, and blood pressure 120/90 mm Hg. The physical exam shows increased resonance to percussion, decreased breath sounds, and crackles at the lung base. Chest radiography shows signs of pulmonary hyperinflation. Spirometry shows a forced expiratory volume in the first second (FEV1) of 48%, a forced vital capacity (FVC) of 85%, and an FEV1/FVC ratio of 56%. According to these results, what is the most likely diagnosis?", "answer": "Chronic obstructive pulmonary disease (COPD)", "options": {"A": "Asthma", "B": "Lymphangioleiomyomatosis", "C": "Chronic obstructive pulmonary disease (COPD)", "D": "Heart failure"}, "meta_info": "step1", "answer_idx": "C", "metamap_phrases": ["year old man presents", "office due to shortness of breath", "moderate exertion", "slightly productive cough", "medical history of", "years", "heavy smoking", "include", "heart rate", "min", "respiratory rate 27 min", "blood pressure", "90 mm Hg", "physical exam shows increased resonance", "percussion", "decreased breath sounds", "crackles", "lung base", "Chest radiography shows signs", "pulmonary hyperinflation", "Spirometry shows", "forced expiratory volume", "first second", "FEV1", "48", "forced vital capacity", "85", "FEV1 FVC ratio", "results", "most likely diagnosis"]}
